Provider First Line Business Practice Location Address:
13040 HIGHWAY 12
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OROFINO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83544-9330
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-476-0329
Provider Business Practice Location Address Fax Number:
208-476-0349
Provider Enumeration Date:
08/10/2006