Provider First Line Business Practice Location Address:
380 WASHINGTON AVE
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
KETCHUM
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83340
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-342-7700
Provider Business Practice Location Address Fax Number:
208-342-8003
Provider Enumeration Date:
07/25/2008