Provider First Line Business Practice Location Address:
660 2ND AVE SOUTH, UNIT A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KETCHUM
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83340-6997
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-720-3087
Provider Business Practice Location Address Fax Number:
208-727-0001
Provider Enumeration Date:
01/25/2007