Provider First Line Business Practice Location Address:
102 E ELM AVENUE
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-819-8413
Provider Business Practice Location Address Fax Number:
208-485-4781
Provider Enumeration Date:
10/19/2018