Provider First Line Business Practice Location Address:
306 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KAMIAH
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83536-6701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-935-7855
Provider Business Practice Location Address Fax Number:
208-935-7855
Provider Enumeration Date:
04/16/2013