Provider First Line Business Practice Location Address:
1115 B STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLUMMER
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83851-0388
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-686-1449
Provider Business Practice Location Address Fax Number:
208-686-5813
Provider Enumeration Date:
04/26/2012