Provider First Line Business Practice Location Address:
2007 E QUAIL RUN RD # 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EMMETT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83617-5059
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-365-2525
Provider Business Practice Location Address Fax Number:
208-365-2234
Provider Enumeration Date:
08/26/2011