Provider First Line Business Practice Location Address:
503 BROADWAY AVE S
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
BUHL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83316-1312
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-944-9008
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/03/2011