Provider First Line Business Practice Location Address:
1501 HILAND AVE
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:
83318-2682
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-677-6530
Provider Business Practice Location Address Fax Number:
208-677-6306
Provider Enumeration Date:
11/23/2011