Provider First Line Business Practice Location Address:
819 HWY 2 PIONEER SQ. 204
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANDPOINT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83864-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-265-0745
Provider Business Practice Location Address Fax Number:
208-255-1543
Provider Enumeration Date:
04/06/2007