Provider First Line Business Practice Location Address:
413 SW 5TH AVE
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-8364
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-370-2020
Provider Business Practice Location Address Fax Number:
208-600-6899
Provider Enumeration Date:
06/24/2010