Provider First Line Business Practice Location Address:
111 BEAVER GRADE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAPWAI
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83540-0367
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-843-2271
Provider Business Practice Location Address Fax Number:
208-843-2658
Provider Enumeration Date:
09/28/2007