Provider First Line Business Practice Location Address:
931 CENTER ST W STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KIMBERLY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83341-5326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-423-9999
Provider Business Practice Location Address Fax Number:
208-423-9998
Provider Enumeration Date:
05/24/2016