Provider First Line Business Practice Location Address:
170 SOUTH SENECA SPRINGS WAY
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
STAR
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83669
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-898-4112
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/03/2007