Provider First Line Business Practice Location Address:
2121 N GARNET CREEK AVE
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:
83669-8001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-740-0544
Provider Business Practice Location Address Fax Number:
208-906-8680
Provider Enumeration Date:
09/24/2018