Provider First Line Business Practice Location Address:
1403 LEADORE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALMON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83467-3622
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-756-6383
Provider Business Practice Location Address Fax Number:
208-756-1312
Provider Enumeration Date:
07/07/2006