Provider First Line Business Practice Location Address:
235 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PAYETTE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83661-2523
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
385-320-6030
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/02/2026