Provider First Line Business Practice Location Address:
911 S HIGHWAY 30
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HEYBURN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83336-5001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-679-2273
Provider Business Practice Location Address Fax Number:
208-679-3368
Provider Enumeration Date:
11/02/2010