Provider First Line Business Practice Location Address:
895 N 6TH E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MTN HOME
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83647-2207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-580-2661
Provider Business Practice Location Address Fax Number:
208-587-8406
Provider Enumeration Date:
03/27/2007