Provider First Line Business Practice Location Address:
304 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLEVUE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83313-6057
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-788-2006
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/02/2016