Provider First Line Business Practice Location Address:
119 S OWYHEE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83705-1631
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-440-8392
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/09/2026