Provider First Line Business Practice Location Address:
315 E ELM STREET
Provider Second Line Business Practice Location Address:
STE 350
Provider Business Practice Location Address City Name:
CALDWELL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-454-6363
Provider Business Practice Location Address Fax Number:
208-454-3512
Provider Enumeration Date:
05/20/2006