Provider First Line Business Practice Location Address:
601 EAST 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:
83537-0160
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-289-3221
Provider Business Practice Location Address Fax Number:
208-289-3721
Provider Enumeration Date:
07/24/2006