Provider First Line Business Practice Location Address:
265 N 3RD E
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:
83647-2734
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-587-8415
Provider Business Practice Location Address Fax Number:
208-587-8416
Provider Enumeration Date:
10/20/2014