Provider First Line Business Practice Location Address:
333 MAIN STREET SOUTH
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
KETCHUM
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83340
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-726-8272
Provider Business Practice Location Address Fax Number:
208-726-8272
Provider Enumeration Date:
09/13/2006