Provider First Line Business Practice Location Address:
425 NORTH OVERLAND AVENUE
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-679-1679
Provider Business Practice Location Address Fax Number:
208-679-3679
Provider Enumeration Date:
06/18/2008