Provider First Line Business Practice Location Address:
EIGHT 2ND STREET WEST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOMEDALE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83628
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-337-6101
Provider Business Practice Location Address Fax Number:
208-337-6102
Provider Enumeration Date:
08/15/2006