Provider First Line Business Practice Location Address:
117 ASH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLEVUE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83313-5226
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-788-4335
Provider Business Practice Location Address Fax Number:
208-788-0098
Provider Enumeration Date:
02/15/2007