Provider First Line Business Practice Location Address:
3607 KOOTENAI ST
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:
83705-2250
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-899-2242
Provider Business Practice Location Address Fax Number:
208-338-5440
Provider Enumeration Date:
07/17/2007