Provider First Line Business Practice Location Address:
733 N. MAIN STREET
Provider Second Line Business Practice Location Address:
SUITE G
Provider Business Practice Location Address City Name:
BELLEVUE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83313
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-725-3680
Provider Business Practice Location Address Fax Number:
208-595-2276
Provider Enumeration Date:
02/22/2012