Provider First Line Business Practice Location Address:
211 N WHITLEY DR
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
FRUITLAND
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83619-2704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-452-4808
Provider Business Practice Location Address Fax Number:
208-452-4816
Provider Enumeration Date:
09/07/2006