Provider First Line Business Practice Location Address:
152 S 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTPELIER
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83254-1538
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-904-3600
Provider Business Practice Location Address Fax Number:
208-904-0556
Provider Enumeration Date:
11/05/2015