Provider First Line Business Practice Location Address:
618 W COLLEGE AVE STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST MARIES
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83861-5010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
202-082-6125
Provider Business Practice Location Address Fax Number:
208-423-0345
Provider Enumeration Date:
01/29/2026