Provider First Line Business Practice Location Address:
3011 S TAGISH WAY
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:
83642-9157
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-283-9398
Provider Business Practice Location Address Fax Number:
208-288-2535
Provider Enumeration Date:
12/18/2006