Provider First Line Business Practice Location Address:
610 CEDAR ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALLACE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83873-2233
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-784-8777
Provider Business Practice Location Address Fax Number:
208-784-3533
Provider Enumeration Date:
08/22/2024