Provider First Line Business Practice Location Address:
371 W FIR ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELLEY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83274-1456
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-357-7611
Provider Business Practice Location Address Fax Number:
208-357-1805
Provider Enumeration Date:
05/10/2006