Provider First Line Business Practice Location Address:
486 W 1ST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLENNS FERRY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83623-2701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-366-7416
Provider Business Practice Location Address Fax Number:
208-366-2595
Provider Enumeration Date:
11/23/2012