Provider First Line Business Practice Location Address:
MISSION ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT HALL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83203-0717
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-328-5456
Provider Business Practice Location Address Fax Number:
208-238-5465
Provider Enumeration Date:
07/28/2006