Provider First Line Business Practice Location Address:
418 ONEIDA ST
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:
83350-1748
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-436-5855
Provider Business Practice Location Address Fax Number:
208-436-5310
Provider Enumeration Date:
06/22/2010