Provider First Line Business Practice Location Address:
1945 HILAND AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
BURLEY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83318-2714
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-678-0900
Provider Business Practice Location Address Fax Number:
208-678-0909
Provider Enumeration Date:
12/06/2006