Provider First Line Business Practice Location Address:
2944 N GOVERNMENT WAY
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:
83815-3751
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-667-1195
Provider Business Practice Location Address Fax Number:
208-667-0985
Provider Enumeration Date:
07/26/2006