Provider First Line Business Practice Location Address:
2020 S JOHNS AVE STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EMMETT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83617-1386
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-369-4340
Provider Business Practice Location Address Fax Number:
208-369-4341
Provider Enumeration Date:
06/08/2016