Provider First Line Business Practice Location Address:
600 E STATE ST
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
EAGLE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83616-6081
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-367-4700
Provider Business Practice Location Address Fax Number:
208-367-4705
Provider Enumeration Date:
04/05/2006