Provider First Line Business Practice Location Address:
147 2ND W STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST. ANTHONY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83445
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-624-3146
Provider Business Practice Location Address Fax Number:
208-624-3442
Provider Enumeration Date:
01/23/2007