Provider First Line Business Practice Location Address:
413 PINE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALLACE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83873-2256
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-752-4681
Provider Business Practice Location Address Fax Number:
208-752-1259
Provider Enumeration Date:
06/05/2008