Provider First Line Business Practice Location Address:
1301 MAIN ST.
Provider Second Line Business Practice Location Address:
SUITE 3B
Provider Business Practice Location Address City Name:
SALMON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83467
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-756-2927
Provider Business Practice Location Address Fax Number:
208-756-1518
Provider Enumeration Date:
09/17/2010