Provider First Line Business Practice Location Address:
2205 JACKSON CREEK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COUNCIL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83612-5244
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-812-2211
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/22/2020