Provider First Line Business Practice Location Address:
431 MAIN ST
Provider Second Line Business Practice Location Address:
CABIN
Provider Business Practice Location Address City Name:
CHALLIS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83278
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-365-8146
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/03/2026