Provider First Line Business Practice Location Address: 
660 2ND AVE S
    Provider Second Line Business Practice Location Address: 
SUITE 2A
    Provider Business Practice Location Address City Name: 
KETCHUM
    Provider Business Practice Location Address State Name: 
ID
    Provider Business Practice Location Address Postal Code: 
83340-6663
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
503-956-1747
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
04/11/2007