Provider First Line Business Practice Location Address:
150 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WENDELL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83355
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-536-2418
Provider Business Practice Location Address Fax Number:
208-536-2629
Provider Enumeration Date:
01/24/2007