Provider First Line Business Practice Location Address:
233 E LOCUST 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:
83814-5748
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-765-8016
Provider Business Practice Location Address Fax Number:
208-765-0690
Provider Enumeration Date:
07/10/2006