Provider First Line Business Practice Location Address:
1034 N 3RD ST
Provider Second Line Business Practice Location Address:
SUITE 1
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:
83814-3145
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-651-0598
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/22/2011