Provider First Line Business Practice Location Address:
933 N. KINGS ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW PLYMOUTH
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83687
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-971-2474
Provider Business Practice Location Address Fax Number:
208-203-9158
Provider Enumeration Date:
08/01/2007