Provider First Line Business Practice Location Address:
2220 OLD PENITENTIARY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83712-8249
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-334-2235
Provider Business Practice Location Address Fax Number:
208-334-2382
Provider Enumeration Date:
04/10/2007