Provider First Line Business Practice Location Address:
715 SW 3RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRUITLAND
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83619-2583
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-452-4303
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/16/2008