Provider First Line Business Practice Location Address:
1031 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURLEY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83318-2029
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-803-2186
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/21/2026