Provider First Line Business Practice Location Address:
1321 W NORTHWOOD CENTER CT
Provider Second Line Business Practice Location Address:
SUITE B
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:
83814-4944
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-665-7055
Provider Business Practice Location Address Fax Number:
208-665-7093
Provider Enumeration Date:
10/02/2007