Provider First Line Business Practice Location Address:
820 SPRAGUE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BUHL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83316-1827
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-543-6401
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/04/2022