Provider First Line Business Practice Location Address:
762 1/2 WASHINGTON 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:
83254-1422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-847-1700
Provider Business Practice Location Address Fax Number:
208-847-1578
Provider Enumeration Date:
03/29/2006