Provider First Line Business Practice Location Address:
1580 E STATE ST
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
EAGLE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83616-6853
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-939-3737
Provider Business Practice Location Address Fax Number:
208-939-2538
Provider Enumeration Date:
10/30/2014