Provider First Line Business Practice Location Address:
118 N 7TH ST STE B8
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:
83814-2704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-215-4594
Provider Business Practice Location Address Fax Number:
208-561-7752
Provider Enumeration Date:
12/30/2016