Provider First Line Business Practice Location Address:
1611 N WHITLEY DR
Provider Second Line Business Practice Location Address:
UNIT 1A
Provider Business Practice Location Address City Name:
FRUITLAND
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83619-2177
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-452-0021
Provider Business Practice Location Address Fax Number:
208-452-0019
Provider Enumeration Date:
02/20/2013