Provider First Line Business Practice Location Address:
1500 S WASHINGTON AVE STE C5
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EMMETT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83617-2401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
986-895-4507
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/10/2024