Provider First Line Business Practice Location Address:
143 1/2 E MAIN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIGBY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-745-0400
Provider Business Practice Location Address Fax Number:
208-745-5005
Provider Enumeration Date:
08/30/2006