Provider First Line Business Practice Location Address:
645 E 5TH 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:
83672-2202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-549-0370
Provider Business Practice Location Address Fax Number:
208-302-0855
Provider Enumeration Date:
03/29/2017