Provider First Line Business Practice Location Address:
660 2ND AVE N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KETCHUM
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83340
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-725-0000
Provider Business Practice Location Address Fax Number:
208-725-0066
Provider Enumeration Date:
09/30/2005