Provider First Line Business Practice Location Address:
31 EAST DAVIS STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83866
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-295-9500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/31/2025