Provider First Line Business Practice Location Address:
HIGHWAY 26
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IRWIN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83428
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-483-2405
Provider Business Practice Location Address Fax Number:
208-483-2415
Provider Enumeration Date:
01/24/2007