Provider First Line Business Practice Location Address:
2426 N MERRITT CREEK LOOP, SUITE B
Provider Second Line Business Practice Location Address:
OBOT ROOM #100
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:
83814-4961
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-296-5385
Provider Business Practice Location Address Fax Number:
208-296-5387
Provider Enumeration Date:
01/18/2023