Provider First Line Business Practice Location Address:
HC 67 BOX 680
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLAYTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83227-9702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-838-2431
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/27/2007