Provider First Line Business Practice Location Address:
229 S. 7TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT MARIES
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83861
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-245-5551
Provider Business Practice Location Address Fax Number:
208-245-4921
Provider Enumeration Date:
05/04/2006