Provider First Line Business Practice Location Address:
1107 NW 11TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRUITLAND
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83619-2255
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-452-8700
Provider Business Practice Location Address Fax Number:
208-452-8725
Provider Enumeration Date:
08/09/2005