Provider First Line Business Practice Location Address:
365 CENTER ROAD
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:
83530-0145
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-983-5535
Provider Business Practice Location Address Fax Number:
208-983-5575
Provider Enumeration Date:
11/27/2006