Provider First Line Business Practice Location Address:
1815 AMERICAN LEGION BLVD STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNTAIN HOME
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83647-3166
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-590-1262
Provider Business Practice Location Address Fax Number:
208-277-1342
Provider Enumeration Date:
03/09/2023