Provider First Line Business Practice Location Address:
113 MAIN ST
Provider Second Line Business Practice Location Address:
UNIT 182
Provider Business Practice Location Address City Name:
KIMBERLY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83341
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-904-3500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/07/2025