Provider First Line Business Practice Location Address:
107 N PLYMOUTH AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW PLYMOUTH
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83655
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-549-1732
Provider Business Practice Location Address Fax Number:
208-549-4050
Provider Enumeration Date:
11/15/2010