Provider First Line Business Practice Location Address:
29948 CUT OFF RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CULDESAC
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83524-6180
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-790-7267
Provider Business Practice Location Address Fax Number:
208-790-7267
Provider Enumeration Date:
03/03/2026