Provider First Line Business Practice Location Address:
731 N MAIN ST STE B
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:
83313-5268
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-218-8989
Provider Business Practice Location Address Fax Number:
833-373-0292
Provider Enumeration Date:
05/21/2012