Provider First Line Business Practice Location Address:
212 S 11TH ST STE 1
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:
83814-4000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-667-3113
Provider Business Practice Location Address Fax Number:
951-466-2426
Provider Enumeration Date:
11/03/2010