Provider First Line Business Practice Location Address:
11104 W. STATE ST.
Provider Second Line Business Practice Location Address:
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:
208-286-7967
Provider Business Practice Location Address Fax Number:
208-286-9047
Provider Enumeration Date:
09/11/2007