Provider First Line Business Practice Location Address:
575 OLD HIGHWAY 30
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNTAIN HOME
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83647-6289
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-580-4269
Provider Business Practice Location Address Fax Number:
888-655-0865
Provider Enumeration Date:
12/06/2018