Provider First Line Business Practice Location Address:
150 126TH ST STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OROFINO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83544-5016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-476-3714
Provider Business Practice Location Address Fax Number:
208-476-5635
Provider Enumeration Date:
03/24/2008