Provider First Line Business Practice Location Address:
207 E 12TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EMMETT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83617-3626
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-365-1065
Provider Business Practice Location Address Fax Number:
208-365-1068
Provider Enumeration Date:
12/12/2019