Provider First Line Business Practice Location Address:
150 N 200 W
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:
83252-1239
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-766-2231
Provider Business Practice Location Address Fax Number:
208-766-4819
Provider Enumeration Date:
08/31/2011