Provider First Line Business Practice Location Address:
3765 HIGHWAY 20 S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ISLAND PARK
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83429
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-558-7766
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/05/2008