Provider First Line Business Practice Location Address:
112 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MELBA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83641-5197
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-495-9809
Provider Business Practice Location Address Fax Number:
208-495-9068
Provider Enumeration Date:
08/26/2022