Provider First Line Business Practice Location Address:
119 N WARDWELL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EMMETT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83617-3040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-365-6311
Provider Business Practice Location Address Fax Number:
208-365-1003
Provider Enumeration Date:
07/07/2006