Provider First Line Business Practice Location Address:
828 CENTER AVE
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:
83661-2536
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-642-2344
Provider Business Practice Location Address Fax Number:
208-642-4060
Provider Enumeration Date:
05/28/2006