Provider First Line Business Practice Location Address:
201 POLE LINE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALMON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83467
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-756-2016
Provider Business Practice Location Address Fax Number:
208-756-4848
Provider Enumeration Date:
03/11/2016