Provider First Line Business Practice Location Address:
1636 S LAKE CREST WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAGLE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83616-7142
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-939-9131
Provider Business Practice Location Address Fax Number:
208-345-1890
Provider Enumeration Date:
09/06/2005