Provider First Line Business Practice Location Address:
1010 W 17TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURLEY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83318-1746
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-678-0101
Provider Business Practice Location Address Fax Number:
208-678-0303
Provider Enumeration Date:
04/19/2019