Provider First Line Business Practice Location Address:
170 RED FIR RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KOOSKIA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83539-5131
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-791-9582
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/18/2025