Provider First Line Business Practice Location Address:
413 N ALLUMBAUGH ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83704-9212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-323-1125
Provider Business Practice Location Address Fax Number:
208-323-9604
Provider Enumeration Date:
10/07/2014