Provider First Line Business Practice Location Address:
504 N. DIVISION ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PINEHURST
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83850
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-682-3920
Provider Business Practice Location Address Fax Number:
208-682-3939
Provider Enumeration Date:
04/11/2013