Provider First Line Business Practice Location Address:
1229 COUNTRY CLUB RD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KELLOGG
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83837
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-784-1433
Provider Business Practice Location Address Fax Number:
877-580-3806
Provider Enumeration Date:
06/24/2011