Provider First Line Business Practice Location Address:
1118 NW 16TH ST
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
FRUITLAND
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83619-2271
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-452-2510
Provider Business Practice Location Address Fax Number:
208-452-2513
Provider Enumeration Date:
10/11/2005