Provider First Line Business Practice Location Address:
1522 MICHAEL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EMMETT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83617-9442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-901-2891
Provider Business Practice Location Address Fax Number:
208-365-4205
Provider Enumeration Date:
11/18/2015