Provider First Line Business Practice Location Address:
1100 A ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLUMMER
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83851
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-686-1931
Provider Business Practice Location Address Fax Number:
208-686-8052
Provider Enumeration Date:
11/21/2005