Provider First Line Business Practice Location Address:
230 E 5TH N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNTAIN HOME
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83647-2749
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-587-8944
Provider Business Practice Location Address Fax Number:
208-587-6105
Provider Enumeration Date:
03/12/2007