Provider First Line Business Practice Location Address:
1520 W STATE ST
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83702-4085
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-343-3883
Provider Business Practice Location Address Fax Number:
208-287-2010
Provider Enumeration Date:
02/25/2008