Provider First Line Business Practice Location Address:
2290 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:
83815-8424
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-772-7994
Provider Business Practice Location Address Fax Number:
208-772-5916
Provider Enumeration Date:
03/30/2021