Provider First Line Business Practice Location Address:
201 N WASHINGTON AVENUE
Provider Second Line Business Practice Location Address:
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:
208-914-5822
Provider Business Practice Location Address Fax Number:
208-726-1179
Provider Enumeration Date:
07/18/2012