Provider First Line Business Practice Location Address:
213 W APPLEWAY
Provider Second Line Business Practice Location Address:
STE 7
Provider Business Practice Location Address City Name:
COEUR DALENE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83815
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-666-1000
Provider Business Practice Location Address Fax Number:
208-665-7749
Provider Enumeration Date:
12/13/2006