Provider First Line Business Practice Location Address:
102 S 1ST AVE
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
SANDPOINT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83864-1398
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-550-8861
Provider Business Practice Location Address Fax Number:
208-263-1796
Provider Enumeration Date:
10/12/2012