Provider First Line Business Practice Location Address:
201 N 8TH ST STE 4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT MARIES
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83861-1869
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-597-7639
Provider Business Practice Location Address Fax Number:
208-717-9450
Provider Enumeration Date:
08/28/2020