Provider First Line Business Practice Location Address:
169 S EMERSON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELLEY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83274-1226
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-357-5733
Provider Business Practice Location Address Fax Number:
208-357-2240
Provider Enumeration Date:
07/24/2007