Provider First Line Business Practice Location Address:
330 W. ASH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GENESEE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83832
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-285-1161
Provider Business Practice Location Address Fax Number:
208-285-1495
Provider Enumeration Date:
02/06/2007