Provider First Line Business Practice Location Address:
740 MCKINLEY AVE
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:
83837-2693
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-786-9303
Provider Business Practice Location Address Fax Number:
208-783-4302
Provider Enumeration Date:
10/03/2011