Provider First Line Business Practice Location Address:
4799 RIVER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BUHL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83316-5104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-787-1304
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/03/2025