Provider First Line Business Practice Location Address: 
167 E 1ST S
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
RIGBY
    Provider Business Practice Location Address State Name: 
ID
    Provider Business Practice Location Address Postal Code: 
83442-1401
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
208-745-8747
    Provider Business Practice Location Address Fax Number: 
208-745-9396
    Provider Enumeration Date: 
11/19/2012