Provider First Line Business Practice Location Address:
195 S 300 E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MALAD CITY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83252-1343
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-534-6080
Provider Business Practice Location Address Fax Number:
208-550-3825
Provider Enumeration Date:
09/29/2026