Provider First Line Business Practice Location Address:
136 S ACADEMY AVE STE C
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:
83616-6541
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-912-6621
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/27/2010