Provider First Line Business Practice Location Address:
9816 I STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WORLEY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83876
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-686-1883
Provider Business Practice Location Address Fax Number:
208-686-3604
Provider Enumeration Date:
09/20/2005