Provider First Line Business Practice Location Address:
1820 W GOLF COURSE RD
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:
83815-1627
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-666-9900
Provider Business Practice Location Address Fax Number:
208-765-6587
Provider Enumeration Date:
02/27/2007