Provider First Line Business Practice Location Address:
1906 FAIRVIEW AVE
Provider Second Line Business Practice Location Address:
STE 230
Provider Business Practice Location Address City Name:
CALDWELL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83605-5407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-429-4667
Provider Business Practice Location Address Fax Number:
208-442-6520
Provider Enumeration Date:
07/29/2009