Provider First Line Business Practice Location Address:
650 N STATE ST
Provider Second Line Business Practice Location Address:
SUITE #1
Provider Business Practice Location Address City Name:
SHELLEY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83274-5167
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-357-2225
Provider Business Practice Location Address Fax Number:
208-357-2224
Provider Enumeration Date:
03/15/2007