Provider First Line Business Practice Location Address:
3650 N GOVERNMENT WAY
Provider Second Line Business Practice Location Address:
SUITE L
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:
83815-8331
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-676-1693
Provider Business Practice Location Address Fax Number:
208-676-1030
Provider Enumeration Date:
08/14/2008