Provider First Line Business Practice Location Address:
640 HIGHWAY 16
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:
83617-9461
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-365-4128
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/01/2011