Provider First Line Business Practice Location Address:
742 E STATE STREET
Provider Second Line Business Practice Location Address:
SUITE 160
Provider Business Practice Location Address City Name:
EAGLE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-938-4764
Provider Business Practice Location Address Fax Number:
208-938-1698
Provider Enumeration Date:
01/18/2007