Provider First Line Business Practice Location Address:
166 SO 5TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTPELIER
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83254-1557
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-847-3847
Provider Business Practice Location Address Fax Number:
208-847-1620
Provider Enumeration Date:
10/05/2006