Provider First Line Business Practice Location Address:
4424 N 1500 E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BUHL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83316-5238
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-543-6876
Provider Business Practice Location Address Fax Number:
208-543-2542
Provider Enumeration Date:
06/01/2007