Provider First Line Business Practice Location Address:
9321 N GOVERNMENT WAY STE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAYDEN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83835-8263
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-664-0165
Provider Business Practice Location Address Fax Number:
208-664-5695
Provider Enumeration Date:
04/20/2026