Provider First Line Business Practice Location Address:
104 N BRIDGE ST
Provider Second Line Business Practice Location Address:
SUITE 112
Provider Business Practice Location Address City Name:
SAINT ANTHONY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83445-1455
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-624-4411
Provider Business Practice Location Address Fax Number:
208-624-4412
Provider Enumeration Date:
05/11/2017