Provider First Line Business Practice Location Address:
25095 HOMEDALE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILDER
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83676-5811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-695-8490
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/17/2025