Provider First Line Business Practice Location Address:
7763 ELMORE RD
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:
83619-3528
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-452-5240
Provider Business Practice Location Address Fax Number:
208-452-5240
Provider Enumeration Date:
11/20/2006