Provider First Line Business Practice Location Address:
909 SHOUP ST STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALMON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83467-4306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-244-2547
Provider Business Practice Location Address Fax Number:
208-756-2354
Provider Enumeration Date:
02/24/2019