Provider First Line Business Practice Location Address:
427 12TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLUMMER
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83851-4000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-686-1931
Provider Business Practice Location Address Fax Number:
208-686-5133
Provider Enumeration Date:
10/15/2008