Provider First Line Business Practice Location Address:
615 2ND AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEZPERCE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83543-0297
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-937-2551
Provider Business Practice Location Address Fax Number:
208-937-2136
Provider Enumeration Date:
02/13/2007