Provider First Line Business Practice Location Address:
279 E. 3RD N.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SODA SPRINGS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83276
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-390-7216
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/30/2014