Provider First Line Business Practice Location Address:
311 N 10TH ST
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:
83814-4280
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-664-8241
Provider Business Practice Location Address Fax Number:
208-664-8841
Provider Enumeration Date:
02/28/2007