Provider First Line Business Practice Location Address:
524 S 9TH AVE STE 103
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:
83605-5072
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-454-2144
Provider Business Practice Location Address Fax Number:
208-454-2149
Provider Enumeration Date:
03/31/2017