Provider First Line Business Practice Location Address:
520 S MERIDIAN RD STE 60
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:
83642-4533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-996-3444
Provider Business Practice Location Address Fax Number:
208-493-9753
Provider Enumeration Date:
06/19/2019