Provider First Line Business Practice Location Address:
410 E GROVE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PARMA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83660-0054
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-722-5269
Provider Business Practice Location Address Fax Number:
208-722-5179
Provider Enumeration Date:
12/01/2006