Provider First Line Business Practice Location Address:
1900 W PINE AVE
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:
83642-1961
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-350-4160
Provider Business Practice Location Address Fax Number:
208-350-4178
Provider Enumeration Date:
06/13/2006