Provider First Line Business Practice Location Address:
184 W 1ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GEORGETOWN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83239
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-847-0204
Provider Business Practice Location Address Fax Number:
208-847-0204
Provider Enumeration Date:
11/21/2006