Provider First Line Business Practice Location Address:
98 HIGHWAY 30
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FILER
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83328-9602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-738-4440
Provider Business Practice Location Address Fax Number:
208-801-6859
Provider Enumeration Date:
12/11/2023