Provider First Line Business Practice Location Address:
1102 3RD ST
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:
83536-5333
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-935-7702
Provider Business Practice Location Address Fax Number:
208-935-1728
Provider Enumeration Date:
02/14/2011