Provider First Line Business Practice Location Address:
1405 AMERICAN LEGION BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MT HOME
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83647-3129
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-587-1177
Provider Business Practice Location Address Fax Number:
208-587-2277
Provider Enumeration Date:
12/13/2006