Provider First Line Business Practice Location Address:
1299 E IRON EAGLE DR
Provider Second Line Business Practice Location Address:
STE 130
Provider Business Practice Location Address City Name:
EAGLE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83616-6869
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-939-6100
Provider Business Practice Location Address Fax Number:
208-425-6585
Provider Enumeration Date:
11/25/2014