Provider First Line Business Practice Location Address:
409 S 3RD ST STE C
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:
83638-5000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-637-8517
Provider Business Practice Location Address Fax Number:
208-634-5763
Provider Enumeration Date:
12/30/2009