Provider First Line Business Practice Location Address:
3361 NO KID RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KAMIAH
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83536-5002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-553-0284
Provider Business Practice Location Address Fax Number:
208-935-2329
Provider Enumeration Date:
12/19/2011