Provider First Line Business Practice Location Address:
509 NW 16TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRUITLAND
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83619-2219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
385-275-8187
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/02/2026