Provider First Line Business Practice Location Address:
4635 NW 1ST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW PLYMOUTH
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83655-5029
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-994-1150
Provider Business Practice Location Address Fax Number:
208-650-4892
Provider Enumeration Date:
02/25/2026