Provider First Line Business Practice Location Address: 
12400 W OVERLAND RD
    Provider Second Line Business Practice Location Address: 
SUITE 100
    Provider Business Practice Location Address City Name: 
BOISE
    Provider Business Practice Location Address State Name: 
ID
    Provider Business Practice Location Address Postal Code: 
83709-0021
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
208-322-7061
    Provider Business Practice Location Address Fax Number: 
208-321-7052
    Provider Enumeration Date: 
07/11/2014