Provider First Line Business Practice Location Address:
2301 WEST A ST
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
MOSCOW
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83843-4042
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-883-1144
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/19/2006