Provider First Line Business Practice Location Address:
7173 E SUPER 1 LOOP
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
ATHOL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-561-9970
Provider Business Practice Location Address Fax Number:
208-561-9997
Provider Enumeration Date:
05/08/2009