Provider First Line Business Practice Location Address:
315 E ELM
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
CALDWELL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-367-5171
Provider Business Practice Location Address Fax Number:
208-367-5180
Provider Enumeration Date:
08/26/2010