Provider First Line Business Practice Location Address:
1441 NE 10TH AVE
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:
83661-5420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-642-9376
Provider Business Practice Location Address Fax Number:
208-642-9598
Provider Enumeration Date:
09/19/2012