Provider First Line Business Practice Location Address:
1600 OVERLAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURLEY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83318-2434
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-219-4926
Provider Business Practice Location Address Fax Number:
208-878-7073
Provider Enumeration Date:
09/11/2024