Provider First Line Business Practice Location Address:
1601 3RD STREET
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-664-2767
Provider Business Practice Location Address Fax Number:
208-765-0306
Provider Enumeration Date:
10/26/2007