Provider First Line Business Practice Location Address:
400 HWY 55
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HORSESHOE BEND
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83629-9015
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-866-8962
Provider Business Practice Location Address Fax Number:
208-793-4040
Provider Enumeration Date:
02/18/2008