Provider First Line Business Practice Location Address:
158 E MAIN ST STE 4B
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:
83530-2283
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-983-1965
Provider Business Practice Location Address Fax Number:
208-983-1139
Provider Enumeration Date:
04/20/2020