Provider First Line Business Practice Location Address:
2270 HIGHWAY 89
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FISH HAVEN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83287-5139
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-815-6862
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/10/2025