Provider First Line Business Practice Location Address:
101 N COUNCIL AVENUE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
COUNCIL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83612-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-253-6893
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/01/2008