Provider First Line Business Practice Location Address:
721 W. NORTH STREET
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-983-0300
Provider Business Practice Location Address Fax Number:
208-983-9176
Provider Enumeration Date:
10/03/2006