Provider First Line Business Practice Location Address:
3061 S MERIDIAN RD
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-7962
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-631-5063
Provider Business Practice Location Address Fax Number:
208-887-0950
Provider Enumeration Date:
06/28/2006