Provider First Line Business Practice Location Address:
406 S ELLA 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:
83864-1130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-261-2126
Provider Business Practice Location Address Fax Number:
208-216-7446
Provider Enumeration Date:
11/18/2020