Provider First Line Business Practice Location Address: 
1001 N 2ND ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MCCALL
    Provider Business Practice Location Address State Name: 
ID
    Provider Business Practice Location Address Postal Code: 
83638-3849
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
208-634-2433
    Provider Business Practice Location Address Fax Number: 
208-634-3125
    Provider Enumeration Date: 
11/13/2007