Provider First Line Business Practice Location Address:
818 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE H & I
Provider Business Practice Location Address City Name:
SALMON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83467-4350
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-756-4794
Provider Business Practice Location Address Fax Number:
208-756-6828
Provider Enumeration Date:
08/30/2006