Provider First Line Business Practice Location Address:
83 HIGHWAY 95 N
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:
83530-5194
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-983-0235
Provider Business Practice Location Address Fax Number:
208-983-0245
Provider Enumeration Date:
04/22/2013