Provider First Line Business Practice Location Address:
811 NW 12TH ST
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:
83619-2268
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
986-207-1720
Provider Business Practice Location Address Fax Number:
866-531-4582
Provider Enumeration Date:
10/01/2024