Provider First Line Business Practice Location Address:
2200 PARK AVE
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
BURLEY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83318-2186
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-678-8188
Provider Business Practice Location Address Fax Number:
208-678-3170
Provider Enumeration Date:
04/29/2008