Provider First Line Business Practice Location Address:
220 BANNOCK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MALAD CITY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83252-1256
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-766-2600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/14/2005