Provider First Line Business Practice Location Address:
5624 N GOVERNMENT WAY STE 7B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALTON GARDENS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83815-7350
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-762-9890
Provider Business Practice Location Address Fax Number:
208-762-9892
Provider Enumeration Date:
12/18/2006