Provider First Line Business Practice Location Address:
1102 E LOCUST ST
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:
83617-2713
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-365-6004
Provider Business Practice Location Address Fax Number:
208-365-3589
Provider Enumeration Date:
05/11/2017