Provider First Line Business Practice Location Address:
2199 W IRONWOOD CENTER DR
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-625-4888
Provider Business Practice Location Address Fax Number:
208-625-5734
Provider Enumeration Date:
02/06/2007