Provider First Line Business Practice Location Address: 
1322 W KATHLEEN AVE STE 2
    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: 
83815-7365
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
208-664-7300
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/11/2010