Provider First Line Business Practice Location Address:
210 EAST ELLIS STREET SUITE #6
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PAUL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83347
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-353-8887
Provider Business Practice Location Address Fax Number:
208-878-6888
Provider Enumeration Date:
02/20/2019