Provider First Line Business Practice Location Address:
130 MILL RD
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:
83629-5103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-484-1583
Provider Business Practice Location Address Fax Number:
866-453-9292
Provider Enumeration Date:
03/28/2013