Provider First Line Business Practice Location Address:
4 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MALAD CITY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83252-4913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-766-2241
Provider Business Practice Location Address Fax Number:
208-766-0902
Provider Enumeration Date:
12/29/2006