Provider First Line Business Practice Location Address: 
501 W GROVE ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BOISE
    Provider Business Practice Location Address State Name: 
ID
    Provider Business Practice Location Address Postal Code: 
83702-5925
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
208-375-0007
    Provider Business Practice Location Address Fax Number: 
208-658-0578
    Provider Enumeration Date: 
08/08/2006