Provider First Line Business Practice Location Address:
1204 KELSO LAKE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATHOL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83801-9675
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-274-3424
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/15/2026