Provider First Line Business Practice Location Address:
401 W CAMAS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRFIELD
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-764-2677
Provider Business Practice Location Address Fax Number:
208-764-2646
Provider Enumeration Date:
05/31/2006