Provider First Line Business Practice Location Address:
509 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENDRICK
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83537-0131
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-289-5941
Provider Business Practice Location Address Fax Number:
208-289-5942
Provider Enumeration Date:
11/09/2005