Provider First Line Business Practice Location Address:
89 W 2ND S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SODA SPRINGS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83276-1509
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-547-3300
Provider Business Practice Location Address Fax Number:
208-547-3532
Provider Enumeration Date:
11/02/2011