Provider First Line Business Practice Location Address:
3770 E. BLACK CANYON HWY
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:
83617-0678
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-365-3437
Provider Business Practice Location Address Fax Number:
208-365-7235
Provider Enumeration Date:
04/06/2009