Provider First Line Business Practice Location Address:
10717 W STATE ST
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:
83669-6046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-302-6300
Provider Business Practice Location Address Fax Number:
208-302-6355
Provider Enumeration Date:
05/01/2019