Provider First Line Business Practice Location Address:
314 S WASHINGTON AVE
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:
83617-2952
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-999-4999
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/31/2019