Provider First Line Business Practice Location Address:
111 EAST 2ND
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLARK FORK
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83811-0464
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-266-1161
Provider Business Practice Location Address Fax Number:
208-266-0219
Provider Enumeration Date:
08/03/2005