Provider First Line Business Practice Location Address:
208 S KOOTENAI BAY 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:
83864-8819
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-263-7874
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/08/2006