Provider First Line Business Practice Location Address:
1321 OAKLEY AVE #2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURLEY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83318-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-678-3063
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/22/2005