Provider First Line Business Practice Location Address:
4491 N DRESDEN PL STE 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARDEN CITY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83714-1391
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-378-1190
Provider Business Practice Location Address Fax Number:
208-323-6508
Provider Enumeration Date:
11/12/2007