Provider First Line Business Practice Location Address:
1441 NE 10TH AVE STE P1
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:
83661-5420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-739-9853
Provider Business Practice Location Address Fax Number:
208-642-0107
Provider Enumeration Date:
01/21/2020