Provider First Line Business Practice Location Address:
3115 N GOVERNMENT WAY
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
COEUR D ALENE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83815-3790
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-664-4523
Provider Business Practice Location Address Fax Number:
208-664-4444
Provider Enumeration Date:
04/24/2007