Provider First Line Business Practice Location Address:
216 S C 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:
83530-1342
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-983-2300
Provider Business Practice Location Address Fax Number:
208-983-2400
Provider Enumeration Date:
03/02/2007