Provider First Line Business Practice Location Address:
425 S WHITLEY DR STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRUITLAND
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83619-2611
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-230-7452
Provider Business Practice Location Address Fax Number:
208-230-7452
Provider Enumeration Date:
12/16/2025