Provider First Line Business Practice Location Address:
165 WEST MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAVA HOT SPRINGS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83246
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-776-5125
Provider Business Practice Location Address Fax Number:
866-287-2315
Provider Enumeration Date:
03/09/2015