Provider First Line Business Practice Location Address:
1107 S LOGAN 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:
83843-3124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-882-8040
Provider Business Practice Location Address Fax Number:
208-882-9050
Provider Enumeration Date:
01/29/2008