Provider First Line Business Practice Location Address:
460 LINCOLN ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
AMERICAN FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83211-1740
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-226-7644
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/19/2007