Provider First Line Business Practice Location Address:
1407 N WHITLEY DR
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:
83619-2242
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-739-4839
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/22/2026