Provider First Line Business Practice Location Address:
138 E 13TH ST
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:
83318-1808
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-655-5450
Provider Business Practice Location Address Fax Number:
385-225-9327
Provider Enumeration Date:
12/14/2017