Provider First Line Business Practice Location Address:
10706 W STATE ST
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
STAR
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83669
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-286-9890
Provider Business Practice Location Address Fax Number:
208-286-9924
Provider Enumeration Date:
10/25/2007