Provider First Line Business Practice Location Address:
1224 8TH STREET, SUITE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RUPERT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-436-9016
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/30/2016