Provider First Line Business Practice Location Address:
406 N PARK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DIETRICH
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83324-5069
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-544-2158
Provider Business Practice Location Address Fax Number:
208-544-2832
Provider Enumeration Date:
04/06/2007