Provider First Line Business Practice Location Address:
1000 WEST MAIN ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SMELTERVILLE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83868-0219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-784-1178
Provider Business Practice Location Address Fax Number:
208-786-2911
Provider Enumeration Date:
08/20/2007