Provider First Line Business Practice Location Address:
5714 S ASTORIA 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:
83642-6395
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-953-4826
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/12/2025