Provider First Line Business Practice Location Address:
114 AIRSTRIP RD
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:
83845-1800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-597-6574
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/10/2026