Provider First Line Business Practice Location Address:
175 E 50TH ST
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:
83714-1413
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-917-1863
Provider Business Practice Location Address Fax Number:
208-906-0815
Provider Enumeration Date:
07/30/2020