Provider First Line Business Practice Location Address:
148 E 50 S
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:
83252-1368
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-766-8111
Provider Business Practice Location Address Fax Number:
208-766-8111
Provider Enumeration Date:
02/03/2010