Provider First Line Business Practice Location Address:
315 S JOHNS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EMMETT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83617-3030
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-343-2737
Provider Business Practice Location Address Fax Number:
208-342-3238
Provider Enumeration Date:
01/10/2013