Provider First Line Business Practice Location Address:
310 E HIGHWAY 200 SUITE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLARK FORK
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-266-1550
Provider Business Practice Location Address Fax Number:
208-266-1530
Provider Enumeration Date:
07/29/2015