Provider First Line Business Practice Location Address:
413 N ALLUMBAUGH STREET
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-515-7552
Provider Business Practice Location Address Fax Number:
208-343-4458
Provider Enumeration Date:
10/14/2019