Provider First Line Business Practice Location Address:
333 SOUTH MAIN ST.
Provider Second Line Business Practice Location Address:
SUITE 212
Provider Business Practice Location Address City Name:
KETCHUM
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83340-2141
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-725-4049
Provider Business Practice Location Address Fax Number:
208-725-4049
Provider Enumeration Date:
11/21/2006