Provider First Line Business Practice Location Address:
585 WEST BOOTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAVA HOT SPRINGS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83246-0458
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-776-5929
Provider Business Practice Location Address Fax Number:
208-776-5011
Provider Enumeration Date:
11/30/2006