Provider First Line Business Practice Location Address:
124 E 3RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOSCOW
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83843-2906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-883-0523
Provider Business Practice Location Address Fax Number:
208-883-0524
Provider Enumeration Date:
03/21/2007