Provider First Line Business Practice Location Address:
301 SCOTT AVE
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:
83350-1800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-436-6406
Provider Business Practice Location Address Fax Number:
208-436-9678
Provider Enumeration Date:
07/03/2006