Provider First Line Business Practice Location Address:
6176 N GOVERNMENT WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COUR D ALENE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83815
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-762-3027
Provider Business Practice Location Address Fax Number:
208-762-0531
Provider Enumeration Date:
09/13/2006