Provider First Line Business Practice Location Address:
704 SOUTH HWY 30
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRACE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-425-9161
Provider Business Practice Location Address Fax Number:
208-425-3809
Provider Enumeration Date:
01/19/2007