Provider First Line Business Practice Location Address:
1007 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BUHL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83316-1627
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-595-4941
Provider Business Practice Location Address Fax Number:
208-595-4931
Provider Enumeration Date:
12/20/2006