Provider First Line Business Practice Location Address:
373 S. MIDDLE FORK RD.
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:
83622-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-462-3175
Provider Business Practice Location Address Fax Number:
208-462-3175
Provider Enumeration Date:
03/24/2014