Provider First Line Business Practice Location Address:
318 N FLORENCE ST
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:
83530-1876
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-451-4466
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/17/2011