Provider First Line Business Practice Location Address:
29242 N ARCHER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATHOL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83801-5405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-446-6261
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/16/2026