Provider First Line Business Practice Location Address:
398 SCHOOL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HORSESHOE BEND
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83629-8099
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-793-2225
Provider Business Practice Location Address Fax Number:
208-793-2449
Provider Enumeration Date:
01/29/2007