Provider First Line Business Practice Location Address:
115 SOUTH MAIN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOMEDALE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83628
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-337-4383
Provider Business Practice Location Address Fax Number:
208-337-5715
Provider Enumeration Date:
10/04/2006