Provider First Line Business Practice Location Address:
HC 1 BOX 85 M
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHITE BIRD
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83554-9703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-839-2299
Provider Business Practice Location Address Fax Number:
208-839-2858
Provider Enumeration Date:
11/01/2006