Provider First Line Business Practice Location Address:
108 W OWYHEE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOMEDALE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83628-3206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-337-3168
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/15/2012