Provider First Line Business Practice Location Address:
201 N 21ST 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:
83605-4371
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-455-1222
Provider Business Practice Location Address Fax Number:
208-455-2559
Provider Enumeration Date:
12/08/2010