Provider First Line Business Practice Location Address:
405 E MAIN ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
GRANGEVILLE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83530-2239
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-983-0309
Provider Business Practice Location Address Fax Number:
208-983-3083
Provider Enumeration Date:
03/19/2007