Provider First Line Business Practice Location Address:
272 E 36TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARDEN CITY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83714-6523
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-514-0518
Provider Business Practice Location Address Fax Number:
208-486-4009
Provider Enumeration Date:
08/30/2006