Provider First Line Business Practice Location Address:
323 E RIVERSIDE DR
Provider Second Line Business Practice Location Address:
STE 124
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:
208-367-5400
Provider Business Practice Location Address Fax Number:
208-367-5401
Provider Enumeration Date:
11/30/2007