Provider First Line Business Practice Location Address:
605 MAPLE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT ANTHONY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83445-5529
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-624-4002
Provider Business Practice Location Address Fax Number:
208-624-4409
Provider Enumeration Date:
10/31/2006