Provider First Line Business Practice Location Address:
1504 N MAIN ST
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:
83642-1707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-888-2267
Provider Business Practice Location Address Fax Number:
208-288-0260
Provider Enumeration Date:
09/08/2005