Provider First Line Business Practice Location Address:
120 DESERT SAGE WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNTAIN HOME
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83647-1038
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-587-3988
Provider Business Practice Location Address Fax Number:
208-587-3324
Provider Enumeration Date:
03/06/2007