Provider First Line Business Practice Location Address:
7 N 4TH ST E STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOMEDALE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83628-1005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-934-1985
Provider Business Practice Location Address Fax Number:
208-568-2761
Provider Enumeration Date:
08/22/2025