Provider First Line Business Practice Location Address:
100 CENTERVILLE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IDAHO CITY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83631
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-392-4183
Provider Business Practice Location Address Fax Number:
208-392-9954
Provider Enumeration Date:
01/31/2007