Provider First Line Business Practice Location Address:
9652 W STATE STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STAR
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83669-5858
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-286-0766
Provider Business Practice Location Address Fax Number:
208-286-0768
Provider Enumeration Date:
09/15/2006