Provider First Line Business Practice Location Address:
211 E LOGAN ST STE B3
Provider Second Line Business Practice Location Address:
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:
620-221-9664
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/21/2006