Provider First Line Business Practice Location Address:
533 MAIN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST MARIES
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83861-2060
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-245-3420
Provider Business Practice Location Address Fax Number:
208-245-3420
Provider Enumeration Date:
05/02/2012