Provider First Line Business Practice Location Address:
229 S 8TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST MARIES
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83861-1813
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-245-2951
Provider Business Practice Location Address Fax Number:
208-245-9303
Provider Enumeration Date:
11/17/2015