Provider First Line Business Practice Location Address:
107 TOM TA HA CREEK RD
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:
83536-5154
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-827-6962
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/17/2018