Provider First Line Business Practice Location Address:
650 N STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELLEY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83274-4900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-782-4744
Provider Business Practice Location Address Fax Number:
208-906-1554
Provider Enumeration Date:
06/13/2012