Provider First Line Business Practice Location Address:
54 W COURT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEISER
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83672-1941
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-414-3881
Provider Business Practice Location Address Fax Number:
208-414-3882
Provider Enumeration Date:
02/27/2007