Provider First Line Business Practice Location Address:
529 BROADWAY AVE SOUTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BUHL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83316
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-543-6511
Provider Business Practice Location Address Fax Number:
208-543-2960
Provider Enumeration Date:
03/14/2019