Provider First Line Business Practice Location Address:
220 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CASCADE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83611
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-382-3558
Provider Business Practice Location Address Fax Number:
208-382-3668
Provider Enumeration Date:
03/03/2009