Provider First Line Business Practice Location Address:
470 N 3RD E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNTAIN HOME
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83647-2737
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-587-2580
Provider Business Practice Location Address Fax Number:
208-587-9896
Provider Enumeration Date:
10/30/2007