Provider First Line Business Practice Location Address:
111 3RD STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEADORE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83464-0119
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-768-2441
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/17/2011