Provider First Line Business Practice Location Address:
910 NW 16TH ST STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRUITLAND
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83619-2265
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-452-8015
Provider Business Practice Location Address Fax Number:
208-452-8055
Provider Enumeration Date:
08/29/2006