Provider First Line Business Practice Location Address:
205 N BERKLEY STEET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COUNCIL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-253-6850
Provider Business Practice Location Address Fax Number:
208-253-6849
Provider Enumeration Date:
07/13/2010