Provider First Line Business Practice Location Address:
414 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GOODING
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83330-1315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-934-4000
Provider Business Practice Location Address Fax Number:
208-934-8899
Provider Enumeration Date:
08/18/2006