Provider First Line Business Practice Location Address:
120 S 13TH ST
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:
83861-1627
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-245-4363
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/15/2012