Provider First Line Business Practice Location Address:
540 S 16TH 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:
83661-3513
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-297-8889
Provider Business Practice Location Address Fax Number:
208-485-9475
Provider Enumeration Date:
08/05/2019