Provider First Line Business Practice Location Address:
1621 N 3RD ST STE 400
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:
83814-3300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-651-0980
Provider Business Practice Location Address Fax Number:
208-601-6089
Provider Enumeration Date:
06/20/2025