Provider First Line Business Practice Location Address:
229 S 7TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST MARIES
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83861-1803
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-245-5551
Provider Business Practice Location Address Fax Number:
208-245-5246
Provider Enumeration Date:
08/30/2006