Provider First Line Business Practice Location Address:
104 E 4TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLARK FORK
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-946-5100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/06/2015