Provider First Line Business Practice Location Address:
1102 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIGGINS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83549-9700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-484-4609
Provider Business Practice Location Address Fax Number:
208-345-3502
Provider Enumeration Date:
03/31/2006