Provider First Line Business Practice Location Address:
790 W USTICK RD
Provider Second Line Business Practice Location Address:
STE 110
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83646-5558
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-639-3990
Provider Business Practice Location Address Fax Number:
208-639-3992
Provider Enumeration Date:
08/10/2010