Provider First Line Business Practice Location Address:
5207 S MONTANA AVE
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:
83607-1583
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-454-0445
Provider Business Practice Location Address Fax Number:
208-454-0778
Provider Enumeration Date:
01/22/2007