Provider First Line Business Practice Location Address:
210 N IDAHO ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WENDELL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83355-5037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-221-4721
Provider Business Practice Location Address Fax Number:
208-536-5570
Provider Enumeration Date:
03/18/2025