Provider First Line Business Practice Location Address:
2179 E WILBUR AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALTON GARDENS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83815-9511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-691-9934
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/12/2026