Provider First Line Business Practice Location Address:
1104 N VERMONT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRUITLAND
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83619-1000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-452-2663
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/09/2005