Provider First Line Business Practice Location Address:
39 N 1ST E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRESTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83263-1325
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-852-1563
Provider Business Practice Location Address Fax Number:
208-852-1268
Provider Enumeration Date:
06/27/2005