Provider First Line Business Practice Location Address:
412 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83871-0415
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-835-5550
Provider Business Practice Location Address Fax Number:
208-883-6580
Provider Enumeration Date:
04/16/2012