Provider First Line Business Practice Location Address:
36 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOWNEY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83234
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-478-9822
Provider Business Practice Location Address Fax Number:
208-478-6790
Provider Enumeration Date:
04/18/2007