Provider First Line Business Practice Location Address:
921 S ORCHARD ST
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:
83705-1930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-426-9100
Provider Business Practice Location Address Fax Number:
208-426-9104
Provider Enumeration Date:
08/02/2006