Provider First Line Business Practice Location Address:
480 N LATAH ST
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:
83706-2630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-345-8962
Provider Business Practice Location Address Fax Number:
208-345-5207
Provider Enumeration Date:
03/13/2007