Provider First Line Business Practice Location Address:
60 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MALAD CITY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83252-1200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-725-9669
Provider Business Practice Location Address Fax Number:
801-298-4617
Provider Enumeration Date:
06/12/2009