Provider First Line Business Practice Location Address:
126 E MAIN ST
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:
83530-2211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-406-5195
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/06/2007