Provider First Line Business Practice Location Address:
29200 HIGHWAY 95
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PARMA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83660
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-250-5041
Provider Business Practice Location Address Fax Number:
208-722-6205
Provider Enumeration Date:
05/02/2006