Provider First Line Business Practice Location Address:
3568 W INDUSTRIAL LOOP
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:
83815-6016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-444-5683
Provider Business Practice Location Address Fax Number:
208-315-6616
Provider Enumeration Date:
06/01/2026