Provider First Line Business Practice Location Address: 
856 BANKS LOWMAN ROAD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
GARDEN VALLEY
    Provider Business Practice Location Address State Name: 
ID
    Provider Business Practice Location Address Postal Code: 
83622-0270
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
208-462-3533
    Provider Business Practice Location Address Fax Number: 
208-462-3736
    Provider Enumeration Date: 
07/10/2008