Provider First Line Business Practice Location Address:
204 E SUPERIOR ST
Provider Second Line Business Practice Location Address:
SUITE #9
Provider Business Practice Location Address City Name:
SANDPOINT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83864-1275
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-255-5577
Provider Business Practice Location Address Fax Number:
208-255-5577
Provider Enumeration Date:
02/25/2008