Provider First Line Business Practice Location Address:
619 S WASHINGTON ST
Provider Second Line Business Practice Location Address:
STE 202
Provider Business Practice Location Address City Name:
MOSCOW
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83843-3090
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-882-1522
Provider Business Practice Location Address Fax Number:
208-882-1527
Provider Enumeration Date:
11/15/2005