Provider First Line Business Practice Location Address:
507 OREGON STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEARY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83823
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-877-1444
Provider Business Practice Location Address Fax Number:
208-877-9004
Provider Enumeration Date:
03/26/2007