Provider First Line Business Practice Location Address:
158 NORTH FIRST EAST STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DRIGGS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-201-5230
Provider Business Practice Location Address Fax Number:
208-787-5230
Provider Enumeration Date:
11/17/2006