Provider First Line Business Practice Location Address:
1711 S 10TH 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:
83605-4839
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-954-9217
Provider Business Practice Location Address Fax Number:
208-453-1037
Provider Enumeration Date:
09/26/2006