Provider First Line Business Practice Location Address:
2005 ARLINGTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CALDWELL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83605-4808
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-318-1362
Provider Business Practice Location Address Fax Number:
208-345-3502
Provider Enumeration Date:
04/22/2022