Provider First Line Business Practice Location Address:
203 E 4TH ST N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OLDTOWN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83822-9546
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-447-4108
Provider Business Practice Location Address Fax Number:
208-437-0886
Provider Enumeration Date:
03/16/2010