Provider First Line Business Practice Location Address:
700 W IRONWOOD DR
Provider Second Line Business Practice Location Address:
STE 101
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:
83814-2666
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-667-2541
Provider Business Practice Location Address Fax Number:
208-664-1173
Provider Enumeration Date:
06/27/2005