Provider First Line Business Practice Location Address:
1740 N. MILWAUKEE ST.
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-377-9500
Provider Business Practice Location Address Fax Number:
208-377-8449
Provider Enumeration Date:
11/24/2006