Provider First Line Business Practice Location Address:
126 W. IDAHO AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOMEDALE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83628-8362
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-337-7038
Provider Business Practice Location Address Fax Number:
208-337-4652
Provider Enumeration Date:
05/05/2020