Provider First Line Business Practice Location Address:
1400 N. PARK LN.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAGLE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83616-3322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-939-9600
Provider Business Practice Location Address Fax Number:
208-939-6090
Provider Enumeration Date:
09/16/2008