Provider First Line Business Practice Location Address:
2020 BLAINE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CALDWELL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83605-4343
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-880-6127
Provider Business Practice Location Address Fax Number:
208-455-6244
Provider Enumeration Date:
11/29/2006