Provider First Line Business Practice Location Address:
150 S 4TH E STE 3
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:
83647-3000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-587-2133
Provider Business Practice Location Address Fax Number:
208-587-2159
Provider Enumeration Date:
09/08/2017