Provider First Line Business Practice Location Address:
104 N BRIDGE ST
Provider Second Line Business Practice Location Address:
SUITE #117
Provider Business Practice Location Address City Name:
SAINT 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:
208-624-7781
Provider Business Practice Location Address Fax Number:
208-624-7742
Provider Enumeration Date:
03/19/2007