Provider First Line Business Practice Location Address:
120 E PINE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CALDWELL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83605-4836
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-701-0053
Provider Business Practice Location Address Fax Number:
208-957-5461
Provider Enumeration Date:
12/30/2025