Provider First Line Business Practice Location Address:
315 E ELM STREET
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
CALDWELL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83605-4858
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-302-7100
Provider Business Practice Location Address Fax Number:
208-302-7155
Provider Enumeration Date:
04/27/2012