Provider First Line Business Practice Location Address:
180 E PARK ST
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:
83672-2011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-888-1155
Provider Business Practice Location Address Fax Number:
208-888-1156
Provider Enumeration Date:
04/23/2007