Provider First Line Business Practice Location Address:
1072 N LIBERTY STREET
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-302-5800
Provider Business Practice Location Address Fax Number:
208-302-5855
Provider Enumeration Date:
10/26/2006