Provider First Line Business Practice Location Address:
507 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAILEY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83333-8929
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-542-9111
Provider Business Practice Location Address Fax Number:
208-542-9114
Provider Enumeration Date:
10/13/2006