Provider First Line Business Practice Location Address:
109 S. MILL ST.
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-983-0898
Provider Business Practice Location Address Fax Number:
208-983-0897
Provider Enumeration Date:
05/26/2010