Provider First Line Business Practice Location Address:
20 N MAIN ST STE 6
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MALAD CITY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83252-1281
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-766-7623
Provider Business Practice Location Address Fax Number:
833-821-3013
Provider Enumeration Date:
05/09/2023