Provider First Line Business Practice Location Address:
309 E LOGAN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CALDWELL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83605-4863
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-455-0678
Provider Business Practice Location Address Fax Number:
208-455-0679
Provider Enumeration Date:
06/13/2012