Provider First Line Business Practice Location Address:
2290 N CENTER VALLEY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANDPOINT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83864-8684
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-269-2325
Provider Business Practice Location Address Fax Number:
208-441-2641
Provider Enumeration Date:
10/17/2025