Provider First Line Business Practice Location Address:
850 E. CENTER
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POC.
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-232-6227
Provider Business Practice Location Address Fax Number:
208-231-3680
Provider Enumeration Date:
08/09/2013