Provider First Line Business Practice Location Address:
1019 3RD AVE S
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:
83661-2832
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-642-4455
Provider Business Practice Location Address Fax Number:
208-642-1315
Provider Enumeration Date:
11/21/2012