Provider First Line Business Practice Location Address:
134 N STATE ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
PRESTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83263-1143
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-852-3030
Provider Business Practice Location Address Fax Number:
208-852-3031
Provider Enumeration Date:
12/09/2008