Provider First Line Business Practice Location Address:
1509 N WHITLEY DR STE 11
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:
83619-2260
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-212-3151
Provider Business Practice Location Address Fax Number:
208-452-1232
Provider Enumeration Date:
03/14/2007