Provider First Line Business Practice Location Address:
529 F ST
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
RUPERT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83350-1635
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-434-8888
Provider Business Practice Location Address Fax Number:
208-436-1970
Provider Enumeration Date:
07/28/2016