Provider First Line Business Practice Location Address:
1509 N WHITLEY DR
Provider Second Line Business Practice Location Address:
SUITE 11
Provider Business Practice Location Address City Name:
FRUITLAND
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83619-2259
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-739-0982
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/07/2011