Provider First Line Business Practice Location Address:
150 AIKENS RD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
EAGLE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83616-4900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-995-2891
Provider Business Practice Location Address Fax Number:
208-995-3891
Provider Enumeration Date:
06/22/2012