Provider First Line Business Practice Location Address:
121 5TH AVE WEST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GOODING
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83330
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-934-4800
Provider Business Practice Location Address Fax Number:
208-934-9611
Provider Enumeration Date:
11/06/2006