Provider First Line Business Practice Location Address:
2241 OVERLAND AVE
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:
83318-2929
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-312-5407
Provider Business Practice Location Address Fax Number:
208-677-4001
Provider Enumeration Date:
03/29/2016