Provider First Line Business Practice Location Address:
212 N 1ST AVE
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
SANDPOINT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83864-1436
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-267-2167
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/01/2011