Provider First Line Business Practice Location Address:
400 E SPRUCE STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MACKAY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83251-0390
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-588-2262
Provider Business Practice Location Address Fax Number:
208-588-2549
Provider Enumeration Date:
05/17/2007