Provider First Line Business Practice Location Address:
325 W 3RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOSCOW
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83843-2204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-882-8534
Provider Business Practice Location Address Fax Number:
208-882-6866
Provider Enumeration Date:
03/16/2007