Provider First Line Business Practice Location Address:
440 E STATE ST
Provider Second Line Business Practice Location Address:
SUITE 140
Provider Business Practice Location Address City Name:
EAGLE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83616-4966
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-939-7000
Provider Business Practice Location Address Fax Number:
208-939-5807
Provider Enumeration Date:
05/02/2007