Provider First Line Business Practice Location Address: 
463 PERKINS LAKE RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MOYIE SPRINGS
    Provider Business Practice Location Address State Name: 
ID
    Provider Business Practice Location Address Postal Code: 
83845-5104
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
208-267-2975
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/14/2014