Provider First Line Business Practice Location Address:
801 E MULLAN AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OSBURN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83849-0707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-556-4803
Provider Business Practice Location Address Fax Number:
208-556-1023
Provider Enumeration Date:
01/22/2007