Provider First Line Business Practice Location Address:
2426 MERRITT CREEK LOOP
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COUER D'ALENE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-819-2183
Provider Business Practice Location Address Fax Number:
208-209-6063
Provider Enumeration Date:
02/28/2020