Provider First Line Business Practice Location Address:
431 S 12TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT MARIES
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83861-1624
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-699-5694
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/27/2025