Provider First Line Business Practice Location Address:
855 W 6TH S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNTAIN HOME
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83647-3335
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-587-2020
Provider Business Practice Location Address Fax Number:
208-587-3349
Provider Enumeration Date:
09/27/2006