Provider First Line Business Practice Location Address:
5920 N GOVERNMENT WAY STE 4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALTON GARDENS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83815-9200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-989-4935
Provider Business Practice Location Address Fax Number:
208-601-6162
Provider Enumeration Date:
09/03/2024