Provider First Line Business Practice Location Address:
2302 N BOGUS BASIN ROAD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-344-0730
Provider Business Practice Location Address Fax Number:
208-344-0759
Provider Enumeration Date:
10/19/2006