Provider First Line Business Practice Location Address:
652 E 1ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEISER
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83672-2200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-549-0172
Provider Business Practice Location Address Fax Number:
208-549-1148
Provider Enumeration Date:
02/27/2007