Provider First Line Business Practice Location Address:
327 S 20TH ST
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:
83661-3033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-453-1522
Provider Business Practice Location Address Fax Number:
208-453-1591
Provider Enumeration Date:
05/19/2008