Provider First Line Business Practice Location Address:
1103 W IRONWOOD DR STE A
Provider Second Line Business Practice Location Address:
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:
83814-2604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-889-1355
Provider Business Practice Location Address Fax Number:
208-625-2036
Provider Enumeration Date:
10/12/2009