Provider First Line Business Practice Location Address:
102 E 14TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCCAMMON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83250-1680
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-957-3010
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/13/2026