Provider First Line Business Practice Location Address:
212 N 1ST AVE
Provider Second Line Business Practice Location Address:
SUITE G100
Provider Business Practice Location Address City Name:
SANDPOINT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83864-1436
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-255-2004
Provider Business Practice Location Address Fax Number:
208-255-2017
Provider Enumeration Date:
04/10/2007