Provider First Line Business Practice Location Address:
392876 HIGHWAY 95
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLUMMER
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83851-9770
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-699-2703
Provider Business Practice Location Address Fax Number:
509-272-3845
Provider Enumeration Date:
11/18/2008