Provider First Line Business Practice Location Address:
1223 S RAILROAD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUGAR CITY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83448-5072
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-359-0519
Provider Business Practice Location Address Fax Number:
208-359-2493
Provider Enumeration Date:
04/24/2020