Provider First Line Business Practice Location Address:
1530 W STATE ST
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:
83642-8503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-362-5598
Provider Business Practice Location Address Fax Number:
208-362-5598
Provider Enumeration Date:
10/16/2007