Provider First Line Business Practice Location Address:
102 COURTHOUSE DR STE F
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALMON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83467-3905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-768-7376
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/23/2024