Provider First Line Business Practice Location Address:
120 SECOND AVE
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
KETCHUM
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83340
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-726-3457
Provider Business Practice Location Address Fax Number:
208-726-3494
Provider Enumeration Date:
08/07/2007