Provider First Line Business Practice Location Address:
61 E 1ST S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SODA SPRINGS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83276-1437
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-864-8575
Provider Business Practice Location Address Fax Number:
435-417-3113
Provider Enumeration Date:
05/21/2012