Provider First Line Business Practice Location Address:
3709 N LOCUST GROVE RD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83646-6450
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-571-7100
Provider Business Practice Location Address Fax Number:
208-493-4331
Provider Enumeration Date:
01/21/2009