Provider First Line Business Practice Location Address:
423 N 3RD AVE STE 210
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:
83864-1511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-263-2173
Provider Business Practice Location Address Fax Number:
208-263-7441
Provider Enumeration Date:
06/29/2012