Provider First Line Business Practice Location Address:
1200 W CHERRY LN STE 101
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:
83642-4933
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-898-0000
Provider Business Practice Location Address Fax Number:
208-898-9000
Provider Enumeration Date:
08/16/2006