Provider First Line Business Practice Location Address:
1526 S LEVICK 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:
83843-2560
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-882-4923
Provider Business Practice Location Address Fax Number:
208-882-8418
Provider Enumeration Date:
10/06/2006