Provider First Line Business Practice Location Address:
102 QUINN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HORSESHOE BEND
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83629
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-888-3033
Provider Business Practice Location Address Fax Number:
208-888-3393
Provider Enumeration Date:
05/13/2009