Provider First Line Business Practice Location Address:
585 W FIR STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELLEY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83274
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-219-8333
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/11/2023