Provider First Line Business Practice Location Address:
165 W. MAIN
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-233-9135
Provider Business Practice Location Address Fax Number:
208-233-9136
Provider Enumeration Date:
05/05/2017