Provider First Line Business Practice Location Address:
1100 NW 12TH 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:
83619-5040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-452-6556
Provider Business Practice Location Address Fax Number:
541-216-6557
Provider Enumeration Date:
11/03/2006