Provider First Line Business Practice Location Address:
24 E 3RD S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT ANTHONY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83445-1809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-624-4322
Provider Business Practice Location Address Fax Number:
208-624-4634
Provider Enumeration Date:
07/18/2011