Provider First Line Business Practice Location Address:
1210 NW 16TH ST
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:
83619-2202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-452-8600
Provider Business Practice Location Address Fax Number:
208-452-8601
Provider Enumeration Date:
11/02/2005