Provider First Line Business Practice Location Address:
2112 CLEVELAND BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CALDWELL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83605-4432
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-459-5873
Provider Business Practice Location Address Fax Number:
208-459-5854
Provider Enumeration Date:
02/28/2007