Provider First Line Business Practice Location Address:
103 E COLLEGE AVE
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:
83861-2247
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-245-4578
Provider Business Practice Location Address Fax Number:
208-245-5004
Provider Enumeration Date:
07/28/2005