Provider First Line Business Practice Location Address:
589 E STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAGLE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83616-5938
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-939-9195
Provider Business Practice Location Address Fax Number:
208-939-4686
Provider Enumeration Date:
08/15/2005