Provider First Line Business Practice Location Address:
1301 N DIVISION AVE
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:
83864-8268
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-265-0610
Provider Business Practice Location Address Fax Number:
208-265-9192
Provider Enumeration Date:
10/25/2010