Provider First Line Business Practice Location Address:
714 JEFFERSON AVE
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:
83530-1545
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-451-3632
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/28/2026