Provider First Line Business Practice Location Address:
512 E ELM ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CALDWELL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83605-4871
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-370-7004
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/25/2024