Provider First Line Business Practice Location Address:
522 E 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEISER
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83672-2205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-549-2213
Provider Business Practice Location Address Fax Number:
208-549-4187
Provider Enumeration Date:
08/01/2006