Provider First Line Business Practice Location Address:
528 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNTAIN HOME
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83647-2117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-587-3364
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/25/2011