Provider First Line Business Practice Location Address:
145 S PLUMMER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STAR
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83669-6199
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-286-0906
Provider Business Practice Location Address Fax Number:
208-286-0726
Provider Enumeration Date:
06/04/2010