Provider First Line Business Practice Location Address:
4565 FROZEN DOG RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EMMETT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83617-9574
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-706-7918
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/23/2025