Provider First Line Business Practice Location Address:
MISSION RD
Provider Second Line Business Practice Location Address:
BOX 717
Provider Business Practice Location Address City Name:
FORT HALL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-238-5408
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/07/2006