Provider First Line Business Practice Location Address:
592 GIFFORD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AMERICAN FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83211-1314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-226-2476
Provider Business Practice Location Address Fax Number:
208-226-2477
Provider Enumeration Date:
03/28/2008