Provider First Line Business Practice Location Address:
100 HOSPITAL DR
Provider Second Line Business Practice Location Address:
SUITE 109
Provider Business Practice Location Address City Name:
KETCHUM
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83340-3069
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-726-1765
Provider Business Practice Location Address Fax Number:
208-726-2863
Provider Enumeration Date:
07/13/2006