Provider First Line Business Practice Location Address:
1912 E FRANKLIN RD
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:
83642-5906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-342-4659
Provider Business Practice Location Address Fax Number:
208-342-8211
Provider Enumeration Date:
11/04/2020