Provider First Line Business Practice Location Address:
100 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOSEPH
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97846-5033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-340-0290
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/17/2023