Provider First Line Business Practice Location Address:
419 BROADWAY AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BUHL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83316-1310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-543-5353
Provider Business Practice Location Address Fax Number:
208-543-2202
Provider Enumeration Date:
08/04/2010