Provider First Line Business Practice Location Address:
451 4TH ST E
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:
83340-9401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-726-2596
Provider Business Practice Location Address Fax Number:
208-726-8268
Provider Enumeration Date:
11/27/2006