Provider First Line Business Practice Location Address:
1055 RIVERSIDE 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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-476-5777
Provider Business Practice Location Address Fax Number:
208-476-5385
Provider Enumeration Date:
08/13/2006