Provider First Line Business Practice Location Address:
221 MAIN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRAIGMONT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83523
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-924-0055
Provider Business Practice Location Address Fax Number:
208-983-7787
Provider Enumeration Date:
04/02/2007