Provider First Line Business Practice Location Address:
1218 9TH ST STE 10
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RUPERT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83350-2207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-464-8420
Provider Business Practice Location Address Fax Number:
208-436-3956
Provider Enumeration Date:
11/26/2012