Provider First Line Business Practice Location Address:
16 S 9TH 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:
83661-2855
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-642-6022
Provider Business Practice Location Address Fax Number:
208-642-6034
Provider Enumeration Date:
02/23/2023