Provider First Line Business Practice Location Address:
621 N MAIN ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLEVUE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83313
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-725-3145
Provider Business Practice Location Address Fax Number:
541-504-3907
Provider Enumeration Date:
06/23/2006