Provider First Line Business Practice Location Address:
510 OAK ST
Provider Second Line Business Practice Location Address:
ROOM 5
Provider Business Practice Location Address City Name:
NEZPERCE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83543-5064
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-937-2698
Provider Business Practice Location Address Fax Number:
208-937-9235
Provider Enumeration Date:
12/01/2009