Provider First Line Business Practice Location Address:
1620 NORTHWEST BLVD 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COUR D ALENE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-704-5358
Provider Business Practice Location Address Fax Number:
208-765-2558
Provider Enumeration Date:
11/28/2006