Provider First Line Business Practice Location Address: 
8660 W EMERALD ST STE 112
    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: 
83704-4829
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
208-321-7831
    Provider Business Practice Location Address Fax Number: 
208-995-2870
    Provider Enumeration Date: 
11/19/2013