Provider First Line Business Practice Location Address:
133 W AVENUE A
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
JEROME
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83338-2630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-324-2004
Provider Business Practice Location Address Fax Number:
208-324-1154
Provider Enumeration Date:
08/02/2014