Provider First Line Business Practice Location Address:
2443 E 1ST ST
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:
83619-2641
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-707-3796
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/18/2011