Provider First Line Business Practice Location Address:
500 W MAIN ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CASTLEFORD
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83321
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-537-6511
Provider Business Practice Location Address Fax Number:
208-537-6855
Provider Enumeration Date:
01/23/2007