Provider First Line Business Practice Location Address:
202 MCCALEB 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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-588-2603
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/30/2006