Provider First Line Business Practice Location Address:
212 S 11TH ST STE 4B
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:
83814-4000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-578-0839
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/28/2025