Provider First Line Business Practice Location Address:
21 EAST MAPLE STREET
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
HAILEY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83333
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-481-0275
Provider Business Practice Location Address Fax Number:
208-578-7757
Provider Enumeration Date:
08/26/2006