Provider First Line Business Practice Location Address:
102 NORTH PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUGAR CITY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83448
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-356-9351
Provider Business Practice Location Address Fax Number:
208-356-0895
Provider Enumeration Date:
02/28/2007