Provider First Line Business Practice Location Address:
1316 N 4TH ST
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:
83814-3220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-676-0400
Provider Business Practice Location Address Fax Number:
775-587-7671
Provider Enumeration Date:
10/24/2014