Provider First Line Business Practice Location Address:
2302 N BOGUS BASIN RD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83702-0902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-344-0737
Provider Business Practice Location Address Fax Number:
208-344-0759
Provider Enumeration Date:
12/22/2006