Provider First Line Business Practice Location Address:
502 FIRST STREET
Provider Second Line Business Practice Location Address:
BOX 249
Provider Business Practice Location Address City Name:
DEARY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83823-0249
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-877-1408
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/13/2009