Provider First Line Business Practice Location Address:
112 S PLYMOUTH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW PLYMOUTH
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83655-0048
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-278-3406
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/13/2006