Provider First Line Business Practice Location Address:
20 EAST WYOMING
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOMEDALE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83628
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-337-4888
Provider Business Practice Location Address Fax Number:
208-337-4898
Provider Enumeration Date:
09/15/2011