Provider First Line Business Practice Location Address:
547 S FITNESS PL
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
EAGLE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83616-6552
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-939-3986
Provider Business Practice Location Address Fax Number:
208-319-2700
Provider Enumeration Date:
10/20/2006