Provider First Line Business Practice Location Address:
215 UNIVERSITY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GOODING
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83330-6155
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-934-5880
Provider Business Practice Location Address Fax Number:
208-934-5876
Provider Enumeration Date:
12/03/2014