Provider First Line Business Practice Location Address:
919 W CANFIELD 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:
83815-9764
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-758-0560
Provider Business Practice Location Address Fax Number:
208-762-5424
Provider Enumeration Date:
06/12/2006