Provider First Line Business Practice Location Address:
228 E PLAZA ST STE B
Provider Second Line Business Practice Location Address:
PMB#137
Provider Business Practice Location Address City Name:
EAGLE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83616-5982
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-371-5433
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/01/2008