Provider First Line Business Practice Location Address:
667 OLD HIGHWAY 30
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNTAIN HOME
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83647-6202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-587-4804
Provider Business Practice Location Address Fax Number:
208-587-4889
Provider Enumeration Date:
12/08/2006