Provider First Line Business Practice Location Address:
1218 9TH ST
Provider Second Line Business Practice Location Address:
STE 7
Provider Business Practice Location Address City Name:
RUPERT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83350
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-436-3161
Provider Business Practice Location Address Fax Number:
208-436-3163
Provider Enumeration Date:
07/08/2006