Provider First Line Business Practice Location Address:
205 N BERKLEY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COUNCIL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83612-5015
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-253-4957
Provider Business Practice Location Address Fax Number:
208-253-4958
Provider Enumeration Date:
11/07/2016