Provider First Line Business Practice Location Address:
3101 E STATE ST
Provider Second Line Business Practice Location Address:
SUITE 2108
Provider Business Practice Location Address City Name:
EAGLE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83616-6232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-489-4975
Provider Business Practice Location Address Fax Number:
208-489-4089
Provider Enumeration Date:
07/20/2012