Provider First Line Business Practice Location Address:
900 N LIBERTY ST
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83704-8704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-367-5544
Provider Business Practice Location Address Fax Number:
208-367-5543
Provider Enumeration Date:
06/16/2006