Provider First Line Business Practice Location Address:
845 S SUB STATION RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EMMETT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83617-9430
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-369-4510
Provider Business Practice Location Address Fax Number:
208-369-4546
Provider Enumeration Date:
08/29/2019