Provider First Line Business Practice Location Address:
345 PARK AVE
Provider Second Line Business Practice Location Address:
208-752-8221
Provider Business Practice Location Address City Name:
MULLAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83846-0071
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-783-2870
Provider Business Practice Location Address Fax Number:
208-752-8221
Provider Enumeration Date:
02/28/2007