Provider First Line Business Practice Location Address:
413 ALLUMBAUGH ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83704-9212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-362-6162
Provider Business Practice Location Address Fax Number:
208-362-9604
Provider Enumeration Date:
01/16/2007