Provider First Line Business Practice Location Address: 
417 E VEATCH ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MOSCOW
    Provider Business Practice Location Address State Name: 
ID
    Provider Business Practice Location Address Postal Code: 
83843-3570
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
208-476-9217
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/10/2023