Provider First Line Business Practice Location Address:
1005 HIGHWAY 13
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:
83530-5065
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-983-0556
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/26/2018