Provider First Line Business Practice Location Address:
846 6TH AVE S STE B
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:
83661-3520
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-834-1112
Provider Business Practice Location Address Fax Number:
208-741-6667
Provider Enumeration Date:
05/28/2014