Provider First Line Business Practice Location Address:
1400 NORMAL 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:
83318-1952
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-678-1772
Provider Business Practice Location Address Fax Number:
208-678-1777
Provider Enumeration Date:
10/07/2011