Provider First Line Business Practice Location Address:
2502 S JUNIPER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MALTA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83342-8004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-670-0776
Provider Business Practice Location Address Fax Number:
208-670-0776
Provider Enumeration Date:
10/09/2025