Provider First Line Business Practice Location Address:
222 N 2ND ST
Provider Second Line Business Practice Location Address:
SUITE 315
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83702-6109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-336-4825
Provider Business Practice Location Address Fax Number:
208-336-2292
Provider Enumeration Date:
10/04/2006