Provider First Line Business Practice Location Address:
1201 S FIVE MILE RD
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:
83709-1304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-322-5655
Provider Business Practice Location Address Fax Number:
208-323-8160
Provider Enumeration Date:
12/21/2005