Provider First Line Business Practice Location Address:
36 E IDAHO ST # 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEISER
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83672-2566
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-549-2163
Provider Business Practice Location Address Fax Number:
208-549-0806
Provider Enumeration Date:
05/23/2007