Provider First Line Business Practice Location Address:
510 W PALOUSE RIVER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOSCOW
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83843-8901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-882-7586
Provider Business Practice Location Address Fax Number:
208-883-4473
Provider Enumeration Date:
08/24/2006