Provider First Line Business Practice Location Address:
515 PINE ST STE B2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANDPOINT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83864-1640
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-627-8988
Provider Business Practice Location Address Fax Number:
208-263-5581
Provider Enumeration Date:
10/29/2007