Provider First Line Business Practice Location Address:
10 S RIVER STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDVALE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83645
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-550-1605
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/24/2008