Provider First Line Business Practice Location Address:
622 CENTER ST W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KIMBERLY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83341-1720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-423-5001
Provider Business Practice Location Address Fax Number:
208-423-4867
Provider Enumeration Date:
12/16/2015