Provider First Line Business Practice Location Address:
103 S COMMERCIAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EMMETT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83617-2921
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-477-8028
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/12/2009