Provider First Line Business Practice Location Address:
4701 W HIGHWAY 38
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MALAD CITY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83252-6615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-766-2588
Provider Business Practice Location Address Fax Number:
208-766-2588
Provider Enumeration Date:
09/23/2005