Provider First Line Business Practice Location Address:
PO BOX 225
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOYIE SPRINGS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83845-5000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-610-2566
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/20/2025