Provider First Line Business Practice Location Address:
925 2ND AVE NO
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PAYETTE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83661
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-642-4782
Provider Business Practice Location Address Fax Number:
208-642-1748
Provider Enumeration Date:
11/02/2006