Provider First Line Business Practice Location Address:
6555 N OLD HIGHWAY 191
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:
83252-5072
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-317-6270
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/13/2017