Provider First Line Business Practice Location Address:
1027 W PRAIRIE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAYDEN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83835
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-772-2202
Provider Business Practice Location Address Fax Number:
208-772-2213
Provider Enumeration Date:
09/01/2015