Provider First Line Business Practice Location Address:
1150 12TH ST
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:
83226-1040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-879-2366
Provider Business Practice Location Address Fax Number:
208-879-4895
Provider Enumeration Date:
09/28/2006