Provider First Line Business Practice Location Address:
225 CITY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWDALE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83436-7716
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-360-0193
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/06/2026