Provider First Line Business Practice Location Address:
179 W HIGHWAY 52
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:
83617-9737
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-272-9454
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/20/2020