Provider First Line Business Practice Location Address:
1611 N WHITLEY DR
Provider Second Line Business Practice Location Address:
#7
Provider Business Practice Location Address City Name:
FRUITLAND
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83619
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-452-5999
Provider Business Practice Location Address Fax Number:
208-452-4499
Provider Enumeration Date:
06/19/2007