Provider First Line Business Practice Location Address:
121 E 39TH ST STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARDEN CITY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83714-6494
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
925-548-9984
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/20/2026