Provider First Line Business Practice Location Address:
2488 E GREEN CANYON DR
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:
83642-9194
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-761-6341
Provider Business Practice Location Address Fax Number:
208-846-8966
Provider Enumeration Date:
03/27/2007