Provider First Line Business Practice Location Address:
130 S 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTPELIER
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83254-1538
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-847-0806
Provider Business Practice Location Address Fax Number:
208-847-0841
Provider Enumeration Date:
04/22/2009