Provider First Line Business Practice Location Address:
202 E 7TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOSCOW
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83843-3002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-883-3937
Provider Business Practice Location Address Fax Number:
208-883-3211
Provider Enumeration Date:
07/11/2005