Provider First Line Business Practice Location Address:
208 S DIVISION ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PINEHURST
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83850-8700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-682-9170
Provider Business Practice Location Address Fax Number:
208-682-2509
Provider Enumeration Date:
09/26/2025