Provider First Line Business Practice Location Address:
111 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOMEDALE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83628-3421
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-337-4900
Provider Business Practice Location Address Fax Number:
208-337-3736
Provider Enumeration Date:
10/14/2005