Provider First Line Business Practice Location Address:
431 E. MAIN ST.
Provider Second Line Business Practice Location Address:
#994
Provider Business Practice Location Address City Name:
CHALLIS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83226
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-833-3773
Provider Business Practice Location Address Fax Number:
833-839-1175
Provider Enumeration Date:
11/18/2013