Provider First Line Business Practice Location Address:
1361 E 16TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURLEY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83318-2008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-677-5198
Provider Business Practice Location Address Fax Number:
208-678-2245
Provider Enumeration Date:
06/27/2006