Provider First Line Business Practice Location Address:
1218 9TH ST STE 4
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:
83350-2207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-436-4838
Provider Business Practice Location Address Fax Number:
208-436-1561
Provider Enumeration Date:
07/17/2008