Provider First Line Business Practice Location Address:
412 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANGEVILLE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83530-1447
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-983-2422
Provider Business Practice Location Address Fax Number:
208-983-3404
Provider Enumeration Date:
10/26/2007