Provider First Line Business Practice Location Address:
618 W COLLEGE AVE
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:
83861-5010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-680-9042
Provider Business Practice Location Address Fax Number:
877-471-2556
Provider Enumeration Date:
11/15/2012