Provider First Line Business Practice Location Address:
132 S 2ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT MARIES
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83861-2209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
120-824-5391
Provider Business Practice Location Address Fax Number:
120-824-5551
Provider Enumeration Date:
01/17/2013