Provider First Line Business Practice Location Address:
600 CULDESAC AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CULDESAC
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83524-8700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-843-5413
Provider Business Practice Location Address Fax Number:
208-843-2719
Provider Enumeration Date:
04/27/2010