Provider First Line Business Practice Location Address:
1916 N LAKEWOOD DR
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:
83814-2633
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-667-4628
Provider Business Practice Location Address Fax Number:
208-667-6695
Provider Enumeration Date:
09/08/2026