Provider First Line Business Practice Location Address:
100 HOSPITAL DRIVE
Provider Second Line Business Practice Location Address:
STE 109
Provider Business Practice Location Address City Name:
KETCHUM
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83340
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-578-3481
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/09/2006