Provider First Line Business Practice Location Address:
601 EAST MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLISS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83314-0115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-352-4447
Provider Business Practice Location Address Fax Number:
208-352-4649
Provider Enumeration Date:
04/04/2007