Provider First Line Business Practice Location Address:
29 N. MISSION RD
Provider Second Line Business Practice Location Address:
BUILDING 240
Provider Business Practice Location Address City Name:
FORT HALL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83203-0040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-339-9559
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/24/2023