Provider First Line Business Practice Location Address:
1319 HIGHWAY 2 STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANDPOINT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83864-2729
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-263-9080
Provider Business Practice Location Address Fax Number:
208-255-1695
Provider Enumeration Date:
10/06/2005