Provider First Line Business Practice Location Address:
350 MAIN ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND VIEW
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83624
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-834-2929
Provider Business Practice Location Address Fax Number:
208-587-3324
Provider Enumeration Date:
03/07/2007