Provider First Line Business Practice Location Address:
405 S 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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-642-9331
Provider Business Practice Location Address Fax Number:
208-642-1550
Provider Enumeration Date:
05/25/2006