Provider First Line Business Practice Location Address:
124 5TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILDER
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83676-5540
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-482-7430
Provider Business Practice Location Address Fax Number:
208-585-6221
Provider Enumeration Date:
02/22/2017