Provider First Line Business Practice Location Address:
3653 N. LOCUST GROVE ROAD
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:
83646-3653
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-338-5437
Provider Business Practice Location Address Fax Number:
208-939-9811
Provider Enumeration Date:
08/10/2005