Provider First Line Business Practice Location Address:
545 LAKE ST
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:
83341-2039
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-293-4099
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/14/2025