Provider First Line Business Practice Location Address:
201 MAIN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARSING
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83639
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-896-4159
Provider Business Practice Location Address Fax Number:
208-896-4917
Provider Enumeration Date:
03/23/2006