Provider First Line Business Practice Location Address:
566 W PRAIRIE AVE
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:
83815-7766
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-772-9110
Provider Business Practice Location Address Fax Number:
208-772-0590
Provider Enumeration Date:
04/07/2010