Provider First Line Business Practice Location Address:
7665 CUSTER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRUITLAND
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83619-5039
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-271-9362
Provider Business Practice Location Address Fax Number:
208-271-9262
Provider Enumeration Date:
06/12/2009