Provider First Line Business Practice Location Address:
60 FRONTAGE RD
Provider Second Line Business Practice Location Address:
STE A7A
Provider Business Practice Location Address City Name:
GRANGEVILLE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83530-5335
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-983-5345
Provider Business Practice Location Address Fax Number:
208-983-5347
Provider Enumeration Date:
12/18/2006