Provider First Line Business Practice Location Address:
1050 CLINIC RD N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHALLIS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83226-9376
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-879-6671
Provider Business Practice Location Address Fax Number:
208-879-6680
Provider Enumeration Date:
08/08/2006