Provider First Line Business Practice Location Address:
3123 MEDICAL DR
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:
83605-6972
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-367-3131
Provider Business Practice Location Address Fax Number:
208-367-4817
Provider Enumeration Date:
10/15/2018