Provider First Line Business Practice Location Address:
23057 OLD HIGHWAY 30
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:
83607-7785
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-860-2345
Provider Business Practice Location Address Fax Number:
208-459-6921
Provider Enumeration Date:
03/31/2006