Provider First Line Business Practice Location Address:
608 MAIN STREET
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-652-2225
Provider Business Practice Location Address Fax Number:
208-652-2226
Provider Enumeration Date:
06/22/2006