Provider First Line Business Practice Location Address:
13500 S. PLEASANT VALLEY RD
Provider Second Line Business Practice Location Address:
IDAHO STATE CORRECTIONAL INSTITUTION
Provider Business Practice Location Address City Name:
KUNA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-336-0740
Provider Business Practice Location Address Fax Number:
574-722-9523
Provider Enumeration Date:
06/23/2006