Provider First Line Business Practice Location Address:
120 LITTLE WOOD RIVER RD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAREY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83320-0262
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-721-0086
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/23/2008