Provider First Line Business Practice Location Address:
300 SOUTH 3RD EAST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SODA SPRINGS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83276
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-547-2916
Provider Business Practice Location Address Fax Number:
801-387-5333
Provider Enumeration Date:
03/26/2021