Provider First Line Business Practice Location Address:
500 WHITELY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COUNCIL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83612-0814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-741-1372
Provider Business Practice Location Address Fax Number:
208-253-4983
Provider Enumeration Date:
12/02/2013