Provider First Line Business Practice Location Address:
804 S WASHINGTON ST STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOSCOW
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83843-3182
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-883-1152
Provider Business Practice Location Address Fax Number:
208-882-1486
Provider Enumeration Date:
11/24/2014