Provider First Line Business Practice Location Address:
280 W PRAIRIE AVE STE 3
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:
83815-9401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-770-2770
Provider Business Practice Location Address Fax Number:
208-770-2771
Provider Enumeration Date:
10/24/2023