Provider First Line Business Practice Location Address:
1605 S KIMBALL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CALDWELL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83605-4548
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-454-2766
Provider Business Practice Location Address Fax Number:
208-454-2771
Provider Enumeration Date:
08/14/2013