Provider First Line Business Practice Location Address:
5400 W FRANKLIN ROAD
Provider Second Line Business Practice Location Address:
SUITE H
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-345-1170
Provider Business Practice Location Address Fax Number:
208-345-3502
Provider Enumeration Date:
03/31/2006