Provider First Line Business Practice Location Address:
5624 N GOVERNMENT WAY
Provider Second Line Business Practice Location Address:
STE 6
Provider Business Practice Location Address City Name:
DALTON GDNS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83815-7350
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-772-9111
Provider Business Practice Location Address Fax Number:
208-772-9114
Provider Enumeration Date:
07/02/2006