Provider First Line Business Practice Location Address:
700 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOSCOW
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83843-3046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-883-2236
Provider Business Practice Location Address Fax Number:
208-883-6550
Provider Enumeration Date:
09/09/2014