Provider First Line Business Practice Location Address:
611 4TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KAMIAH
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83536-1769
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-413-1200
Provider Business Practice Location Address Fax Number:
208-983-7652
Provider Enumeration Date:
07/09/2015