Provider First Line Business Practice Location Address:
76 WEST MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUBOIS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83423
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-374-5212
Provider Business Practice Location Address Fax Number:
208-374-5212
Provider Enumeration Date:
01/16/2007