Provider First Line Business Practice Location Address:
530 S STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELLEY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83274
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-357-2400
Provider Business Practice Location Address Fax Number:
208-357-2414
Provider Enumeration Date:
02/27/2007