Provider First Line Business Practice Location Address:
2200 PARKE AVE
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
BURLEY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83318-3351
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-678-8980
Provider Business Practice Location Address Fax Number:
208-678-4316
Provider Enumeration Date:
03/29/2007