Provider First Line Business Practice Location Address:
104 W 53RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARDEN CITY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83714-3501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-375-5511
Provider Business Practice Location Address Fax Number:
208-376-4268
Provider Enumeration Date:
06/19/2025