Provider First Line Business Practice Location Address:
2173 OVERLAND AVE
Provider Second Line Business Practice Location Address:
BOX 756
Provider Business Practice Location Address City Name:
BURLEY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83318-2927
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-678-9165
Provider Business Practice Location Address Fax Number:
208-679-5985
Provider Enumeration Date:
05/03/2007