Provider First Line Business Practice Location Address:
12655 S OLD HIGHWAY 91
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARIMO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83214-1613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-254-3306
Provider Business Practice Location Address Fax Number:
208-254-9243
Provider Enumeration Date:
01/29/2007