Provider First Line Business Practice Location Address:
315 E ELM ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
CALDWELL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83605-4857
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-459-7415
Provider Business Practice Location Address Fax Number:
208-453-3232
Provider Enumeration Date:
10/20/2009