Provider First Line Business Practice Location Address:
152 E MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
RIGBY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83442-5266
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-745-7101
Provider Business Practice Location Address Fax Number:
208-745-0068
Provider Enumeration Date:
01/16/2009