Provider First Line Business Practice Location Address:
118 N 7TH ST STE C5
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:
83814-2710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-771-6249
Provider Business Practice Location Address Fax Number:
951-530-8310
Provider Enumeration Date:
01/10/2008