Provider First Line Business Practice Location Address:
1312 S WASHINGTON AVE STE 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EMMETT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83617-3596
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-481-4461
Provider Business Practice Location Address Fax Number:
208-369-4191
Provider Enumeration Date:
10/20/2021