Provider First Line Business Practice Location Address:
113 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KIMBERLY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83341
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-421-9659
Provider Business Practice Location Address Fax Number:
208-268-3878
Provider Enumeration Date:
06/10/2020