Provider First Line Business Practice Location Address:
PO BOX 182
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KIMBERLY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83341-0182
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-904-3500
Provider Business Practice Location Address Fax Number:
208-904-3547
Provider Enumeration Date:
11/14/2025