Provider First Line Business Practice Location Address:
1338 HILAND AVE
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
BURLEY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83318-1561
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-878-4197
Provider Business Practice Location Address Fax Number:
208-878-3638
Provider Enumeration Date:
09/14/2006