Provider First Line Business Practice Location Address:
1159 E. IRON EAGLE DRIVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
EAGLE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-322-3606
Provider Business Practice Location Address Fax Number:
208-327-2109
Provider Enumeration Date:
11/21/2006