Provider First Line Business Practice Location Address:
805 E MULLAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OSBURN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83849
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-556-1139
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/01/2008