Provider First Line Business Practice Location Address:
521 S DIVISION AVE STE 131
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:
83864-2092
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-255-2194
Provider Business Practice Location Address Fax Number:
208-263-0349
Provider Enumeration Date:
05/16/2006