Provider First Line Business Practice Location Address:
306 N MAIN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ABERDEEN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-397-4126
Provider Business Practice Location Address Fax Number:
208-397-4176
Provider Enumeration Date:
11/18/2005