Provider First Line Business Practice Location Address:
3611 S 10TH 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:
83605-6209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-459-3666
Provider Business Practice Location Address Fax Number:
208-455-5058
Provider Enumeration Date:
10/30/2012