Provider First Line Business Practice Location Address:
315 E ELM ST STE 310
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CALDWELL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83605-4881
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-454-2035
Provider Business Practice Location Address Fax Number:
208-454-1065
Provider Enumeration Date:
12/05/2006