Provider First Line Business Practice Location Address:
24 SOUTH 8TH STR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ASHTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83420-0610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-652-3396
Provider Business Practice Location Address Fax Number:
208-652-7924
Provider Enumeration Date:
11/29/2006