Provider First Line Business Practice Location Address:
20 N 12TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PAYETTE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83661-2603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-642-4138
Provider Business Practice Location Address Fax Number:
208-642-9006
Provider Enumeration Date:
01/22/2007