Provider First Line Business Practice Location Address:
1312 S WASHINGTON AVE STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EMMETT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83617-3596
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-365-6800
Provider Business Practice Location Address Fax Number:
208-365-9600
Provider Enumeration Date:
08/27/2026