Provider First Line Business Practice Location Address:
514 N 4TH AVE
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:
83864-1513
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-795-7526
Provider Business Practice Location Address Fax Number:
208-265-2301
Provider Enumeration Date:
01/25/2007