Provider First Line Business Practice Location Address:
1501 HILAND AVE
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:
83318-2682
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-284-1755
Provider Business Practice Location Address Fax Number:
801-262-3897
Provider Enumeration Date:
01/17/2008