Provider First Line Business Practice Location Address:
223 S MAIN 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:
83661-2852
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-649-7221
Provider Business Practice Location Address Fax Number:
208-642-2019
Provider Enumeration Date:
07/14/2006