Provider First Line Business Practice Location Address:
850 W KATHLEEN AVE
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:
83815-9405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-667-7494
Provider Business Practice Location Address Fax Number:
208-765-2236
Provider Enumeration Date:
09/29/2010