Provider First Line Business Practice Location Address:
607 W MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
GRANGEVILLE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83530-1345
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-494-3050
Provider Business Practice Location Address Fax Number:
208-983-1915
Provider Enumeration Date:
12/08/2016