Provider First Line Business Practice Location Address:
1221 W IRONWOOD DR STE 100
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:
83814-1402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-215-8727
Provider Business Practice Location Address Fax Number:
208-625-2069
Provider Enumeration Date:
06/15/2026