Provider First Line Business Practice Location Address:
980 BURLEY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BUHL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83316-1849
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-814-9150
Provider Business Practice Location Address Fax Number:
208-814-9151
Provider Enumeration Date:
06/25/2024