Provider First Line Business Practice Location Address:
208 CENTER 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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-282-6155
Provider Business Practice Location Address Fax Number:
208-254-9372
Provider Enumeration Date:
07/14/2023