Provider First Line Business Practice Location Address:
90 S SUPERIOR STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMBRIDGE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-257-4522
Provider Business Practice Location Address Fax Number:
208-257-4523
Provider Enumeration Date:
06/07/2013