Provider First Line Business Practice Location Address:
79 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOWNEY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83234-4703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-897-5600
Provider Business Practice Location Address Fax Number:
208-897-5603
Provider Enumeration Date:
07/07/2006