Provider First Line Business Practice Location Address:
1523 FAIRVIEW AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CALDWELL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83605-4609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-455-9591
Provider Business Practice Location Address Fax Number:
208-459-2612
Provider Enumeration Date:
11/29/2006