Provider First Line Business Practice Location Address:
700 E STATE ST STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAGLE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83616-5941
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-939-3500
Provider Business Practice Location Address Fax Number:
208-939-9897
Provider Enumeration Date:
01/31/2011