Provider First Line Business Practice Location Address:
777 S LATAH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83705-1501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-907-4704
Provider Business Practice Location Address Fax Number:
208-918-8634
Provider Enumeration Date:
01/17/2025