Provider First Line Business Practice Location Address:
315 N. WHITLEY
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-452-2722
Provider Business Practice Location Address Fax Number:
208-642-8941
Provider Enumeration Date:
11/30/2006