Provider First Line Business Practice Location Address:
1010 STATE 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:
83638-3704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-634-5909
Provider Business Practice Location Address Fax Number:
208-634-5956
Provider Enumeration Date:
12/27/2006