Provider First Line Business Practice Location Address:
206 N. 3RD STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PARMA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83660-0171
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-850-8295
Provider Business Practice Location Address Fax Number:
208-585-6768
Provider Enumeration Date:
04/22/2015