Provider First Line Business Practice Location Address:
119 WEST LOGAN STREET
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
CALDWELL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-454-2050
Provider Business Practice Location Address Fax Number:
208-454-3554
Provider Enumeration Date:
08/23/2006