Provider First Line Business Practice Location Address:
303 ELK CREEK ROAD
Provider Second Line Business Practice Location Address:
SUITE BOX 88
Provider Business Practice Location Address City Name:
IDAHO CITY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83631
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-848-6703
Provider Business Practice Location Address Fax Number:
208-392-4128
Provider Enumeration Date:
08/31/2016