Provider First Line Business Practice Location Address:
515 E 5TH ST. N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURLEY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83318
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-679-3000
Provider Business Practice Location Address Fax Number:
208-679-7644
Provider Enumeration Date:
09/08/2006