Provider First Line Business Practice Location Address:
101 S FREDERICK
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARRISON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83833
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-689-9103
Provider Business Practice Location Address Fax Number:
208-689-3710
Provider Enumeration Date:
02/14/2007