Provider First Line Business Practice Location Address:
1130 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:
83815-8780
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-209-0288
Provider Business Practice Location Address Fax Number:
208-209-0289
Provider Enumeration Date:
03/27/2021