Provider First Line Business Practice Location Address:
101 E BLEEKER AVE
Provider Second Line Business Practice Location Address:
BOX 468
Provider Business Practice Location Address City Name:
COUNCIL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-253-4217
Provider Business Practice Location Address Fax Number:
205-253-4577
Provider Enumeration Date:
10/17/2012