Provider First Line Business Practice Location Address:
240 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SODA SPRINGS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83276-5215
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-221-1196
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/02/2026