Provider First Line Business Practice Location Address:
420 E INDIANA AVE
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:
83814-2989
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-626-2511
Provider Business Practice Location Address Fax Number:
208-561-7222
Provider Enumeration Date:
04/16/2026