Provider First Line Business Practice Location Address:
395 S 16TH 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:
83661-3351
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-642-6160
Provider Business Practice Location Address Fax Number:
208-642-6171
Provider Enumeration Date:
11/17/2011