Provider First Line Business Practice Location Address:
160 N 1ST E
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:
83276-1203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-547-4888
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/13/2006