Provider First Line Business Practice Location Address:
303 MAIN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARSING
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83639
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-869-5563
Provider Business Practice Location Address Fax Number:
208-429-6565
Provider Enumeration Date:
06/25/2007