Provider First Line Business Practice Location Address:
520 BROADWAY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MELBA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83641
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-495-1141
Provider Business Practice Location Address Fax Number:
208-495-1142
Provider Enumeration Date:
01/31/2007