Provider First Line Business Practice Location Address:
6507 GULCH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW PLYMOUTH
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83655-5361
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-739-8499
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/01/2026