Provider First Line Business Practice Location Address:
6101 W HWY 54
Provider Second Line Business Practice Location Address:
SUITE 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:
208-683-0800
Provider Business Practice Location Address Fax Number:
208-683-0900
Provider Enumeration Date:
12/01/2006