Provider First Line Business Practice Location Address:
6101 E HIGHWAY 54
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
ATHOL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83801-6085
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-994-3757
Provider Business Practice Location Address Fax Number:
208-352-3921
Provider Enumeration Date:
08/13/2021