Provider First Line Business Practice Location Address:
1060 AIRPORT ROAD
Provider Second Line Business Practice Location Address:
BOX 586
Provider Business Practice Location Address City Name:
OROFINO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83544-0586
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-476-5615
Provider Business Practice Location Address Fax Number:
208-476-9315
Provider Enumeration Date:
12/13/2006