Provider First Line Business Practice Location Address:
445 S FITNESS PL
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
EAGLE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83616-6828
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-552-7884
Provider Business Practice Location Address Fax Number:
877-552-7885
Provider Enumeration Date:
04/26/2010