Provider First Line Business Practice Location Address:
1026 S CHALLIS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALMON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83467-5441
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-742-1285
Provider Business Practice Location Address Fax Number:
208-742-1283
Provider Enumeration Date:
02/16/2015