Provider First Line Business Practice Location Address:
1252 BENNETT AVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
BURLEY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83318-2664
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-878-3486
Provider Business Practice Location Address Fax Number:
208-878-2005
Provider Enumeration Date:
02/09/2007