Provider First Line Business Practice Location Address: 
211 E COEUR D ALENE AVE STE 102
    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: 
83814-4926
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
208-699-6817
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/26/2010