Provider First Line Business Practice Location Address:
20 N MAIN ST STE 10
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MALAD CITY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83252-1281
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-317-6300
Provider Business Practice Location Address Fax Number:
208-254-3386
Provider Enumeration Date:
04/18/2007