Provider First Line Business Practice Location Address:
501 OAK
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEZPERCE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83543
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-937-2496
Provider Business Practice Location Address Fax Number:
208-937-2497
Provider Enumeration Date:
06/03/2006