Provider First Line Business Practice Location Address:
2240 AMERICAN LEGION BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNTAIN HOME
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83647
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-580-9525
Provider Business Practice Location Address Fax Number:
208-580-9527
Provider Enumeration Date:
02/11/2015