Provider First Line Business Practice Location Address:
1105 MICHIGAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OROFINO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83544-9005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-476-5727
Provider Business Practice Location Address Fax Number:
208-476-4045
Provider Enumeration Date:
06/27/2005