Provider First Line Business Practice Location Address:
64 S STAR RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STAR
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83669-5497
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-268-0089
Provider Business Practice Location Address Fax Number:
208-488-4248
Provider Enumeration Date:
07/27/2012