Provider First Line Business Practice Location Address:
1105 3RD AVE NORTH
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:
208-642-9763
Provider Business Practice Location Address Fax Number:
208-642-3554
Provider Enumeration Date:
10/17/2006