Provider First Line Business Practice Location Address:
701 LEWISTON STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COTTONWOOD
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83522-0137
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-962-3251
Provider Business Practice Location Address Fax Number:
208-962-3722
Provider Enumeration Date:
10/03/2013