Provider First Line Business Practice Location Address:
1620 N WHITLEY DR
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:
83619-2129
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-452-7075
Provider Business Practice Location Address Fax Number:
208-452-7446
Provider Enumeration Date:
06/21/2011