Provider First Line Business Practice Location Address:
3162 N 3350 W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOORE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83255
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-554-4000
Provider Business Practice Location Address Fax Number:
208-554-4001
Provider Enumeration Date:
10/16/2012