Provider First Line Business Practice Location Address:
100 W OVERLAND RD STE 103
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:
83642-3052
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-342-1222
Provider Business Practice Location Address Fax Number:
208-672-8329
Provider Enumeration Date:
01/31/2014