Provider First Line Business Practice Location Address:
219 S WOODDALE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAGLE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83616-7714
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-391-3877
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/31/2026