Provider First Line Business Practice Location Address:
212 N 1ST AVE STE 201
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:
83864-1451
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-304-4123
Provider Business Practice Location Address Fax Number:
208-597-7077
Provider Enumeration Date:
09/09/2009