Provider First Line Business Practice Location Address:
1121 E STATE ST
Provider Second Line Business Practice Location Address:
STE 107
Provider Business Practice Location Address City Name:
EAGLE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83616-6062
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-850-7958
Provider Business Practice Location Address Fax Number:
208-441-9947
Provider Enumeration Date:
03/22/2007