Provider First Line Business Practice Location Address:
622 W NORTH 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:
83530-1240
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-983-0260
Provider Business Practice Location Address Fax Number:
208-983-0047
Provider Enumeration Date:
09/12/2005