Provider First Line Business Practice Location Address:
213 N PLYMOUTH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW PLYMOUTH
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83655-5532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-631-5375
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/17/2018