Provider First Line Business Practice Location Address:
516 BANK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALLACE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83873-2225
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-752-3016
Provider Business Practice Location Address Fax Number:
208-753-1001
Provider Enumeration Date:
04/23/2008