Provider First Line Business Practice Location Address: 
11152 W STATE ST
    Provider Second Line Business Practice Location Address: 
SUITE 103
    Provider Business Practice Location Address City Name: 
STAR
    Provider Business Practice Location Address State Name: 
ID
    Provider Business Practice Location Address Postal Code: 
83669-5216
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
208-703-5088
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
01/28/2015